Management of Skull Base Meningiomas with Extracranial Extension: Resection, Recurrence, and Prognostic Factors

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Zuluaga-García, Esteban Ramírez-Ferrer, Sophie F. Peeters, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6590546/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 19 Jun, 2025 Read the published version in Journal of Neuro-Oncology → Version 1 posted 10 You are reading this latest preprint version Abstract Purpose To assess clinical, radiographic, surgical, and pathological factors affecting outcomes in patients with skull-base meningiomas (SBMs) with extracranial extension, focusing on extent of resection (EOR), recurrence rates, postoperative complications, and skull-base (SB) reconstruction strategies. Methods We conducted a retrospective cohort study of 101 patients with SBMs and transcranial extension treated surgically between 1993 and 2024. Tumors were categorized by the Irish classification (Zones I–III). We collected demographics, imaging, surgical details (approach and EOR), pathology (WHO grade, brain invasion, cranial-nerve involvement), and adjuvant therapy. Primary outcomes included gross total resection (GTR) rate, postoperative complications, progression-free survival (PFS), and overall survival (OS). Multivariable Cox-regression and Firth’s-logistic regression identified independent predictors. Results Zone I was most common (47%), with orbital (41%) and infratemporal-fossa (18%) extension. GTR was achieved in 61.4% overall—highest in Zone I (70.2%). Cerebrospinal-fluid leaks occurred in 8% (highest in Zone III, 27%), and wound infections in 2.9%, none requiring debridement. Tumor recurrence occurred in 40%; subtotal resection (STR; hazard ratio [HR] 2.73, p = 0.014), WHO grade III (HR 27.3, p = 0.003), cranial-nerve dysfunction, and brain invasion independently predicted reduced PFS. STR, Simpson grade > 1, cavernous-sinus invasion, and brain invasion predicted worse OS. Multidisciplinary SB reconstruction using autologous grafts and prosthetic materials (PEEK, titanium mesh) was essential to minimize morbidity. Conclusion SBMs with extracranial extension present complex surgical challenges. EOR, tumor histology, and invasion of critical structures significantly influence recurrence and survival. Tailored surgical planning by zone and comprehensive SB reconstruction are critical to optimize outcomes and reduce postoperative morbidity. Meningioma Intracranial Neoplasm Skull Base Surgery Gross Total Resection Prognostic Factors Postoperative Complications Figures Figure 1 Introduction Skull-base meningiomas (SBMs) represent a distinct subgroup of intracranial meningiomas and are often associated with a more aggressive clinical course despite their typically benign histology [ 1 ]. Their proximity to neurovascular structures and frequent extension into adjacent compartments may limit the extent of resection (EOR), often requiring complex surgical approaches [ 2 ]. Additionally, recurrence risk in SBM follows a prolonged course, with recurrence rates plateauing beyond the 100 months of follow-up [ 3 ]. SBMs occasionally extend into extracranial compartments, such as the infratemporal fossa, pterygopalatine fossa, orbit, nasal cavity, and paranasal sinuses, through anatomical skull base (SB) foramina or through bone erosion [ 4 ]. This transcompartmental behavior often requires a multidisciplinary approach to achieve safe maximal resection and effective reconstruction while minimizing complications [ 5 ]. However, such interventions are associated with a higher risk of postoperative complications, including cerebrospinal fluid (CSF) leakage and flap necrosis, particularly in the context of planned adjuvant radiation therapy [ 6 , 7 ]. Published series report gross total resection (GTR) rates for SBMs with extracranial extension (SBM-EE) ranging from 55–62.3%, with postoperative complication rates approaching 20% [ 5 , 8 ]. Despite these tumors being predominantly WHO grade 1, recurrence rates as high as 35% at five years have been documented [ 8 ]. While prior studies have evaluated the extent of resection (EOR) in SBM-EE, data remain limited regarding the correlation between tumor location, including patterns of extracranial involvement, and recurrence rates, surgical approaches, reconstruction techniques, and outcomes, particularly complications related to SB reconstruction. This study aims to retrospectively assess clinical, radiographic, surgical, pathological, and adjuvant therapy variables associated with outcomes in this anatomically and surgically complex subset of transcranial tumors. The analysis seeks to provide meaningful insights into surgical planning, prognostication, and support the development of multidisciplinary treatment strategies specifically tailored to SBM-EE. Methods Study design and patient data A retrospective cohort study was conducted, including all patients diagnosed with SBM exhibiting transcranial invasion who underwent surgical resection at our institution between January 1993 and August 2024. Histopathological diagnoses were confirmed using the 2007, 2016, or 2021 WHO criteria and reclassified according to the 2021 WHO classification. Institutional Review Board approval was obtained, and data were managed according to ethical standards. Collected variables included demographics (age, sex) and clinical manifestations (e.g., visual impairment, cranial nerve dysfunction). Tumor location was classified according to the Irish et al. system[ 9 ]: Zone I includes tumors originating from the anterior skull base, sella, or clivus with extension into the paranasal sinuses, orbit, or anterolateral foramen magnum (anterior to dentate ligaments); Zone II involves lateral middle fossa lesions extending into the infratemporal or pterygopalatine fossae; and Zone III includes tumors in the posterolateral middle or posterior fossa involving the petrous temporal bone with extension into the ear canal, neck, or posterolateral foramen magnum ( Fig. 1 ) [ 9 ]. Tumors spanning multiple zones were classified according to the predominant tumor volume. Additional data collected included tumor dimensions, extracranial extension, radiographic and histopathological features (WHO grade, Ki-67 index), EOR, Simpson grade, surgical approach, and complications. Adjuvant radiotherapy data, including delivery method and total dose, were recorded. Outcomes were assessed based on recurrence, overall survival (OS), progression-free survival (PFS), and 30-day postoperative complications. Postoperative complications were categorized using the Landriel-Ibáñez system [ 10 ]: Grade I (non-life-threatening, no invasive procedures), Grade II (requiring invasive management), Grade III (life-threatening, ICU treatment), and Grade IV (death due to complications). Recurrence was defined as radiographic tumor progression. Statistical analysis Data were analyzed using descriptive statistics. Depending on distribution, continuous variables were reported as means with standard deviations or analyzed with t-tests or Mann-Whitney U tests. Categorical variables were reported as frequencies and percentages and compared using chi-square tests. One-way ANOVA with Tukey’s post-hoc tests was used to compare subgroup medians. Kaplan–Meier curves estimated PFS and OS, with group differences assessed using the log-rank test. PFS was stratified by treatment modality and tumor characteristics, including radiographic features, cavernous sinus invasion, brain invasion, and proliferation index. Univariable Cox proportional hazards models identified potential prognostic factors for PFS and OS; variables with p < 0.20 were included in multivariable models using stepwise backward elimination. Hazard ratios (HRs) and 95% confidence intervals (CIs) were reported. For predictors of EOR with low event counts, Firth’s bias reduction logistic regression [ 11 ] was applied, including variables such as prior radiation, Irish zone, tumor diameter, and histological grade. Model significance was determined using the likelihood ratio test, with p < 0.05 considered statistically significant. Analyses and data visualizations were conducted using RStudio (version 4.4.2) [ 12 ]. Results Patient and Tumor Characteristics A total of 101 patients were included ( Table 1 ) . The most common clinical presentation was proptosis (55%), followed by visual impairment (49%) and retroocular pain (35%). Tumors were primarily located in zone I (47%), then zone II (36%), and zone III (18%). Frequent extracranial extension sites included the orbit (41%) and infratemporal fossa (18%), while nasal cavity and neck soft tissue involvement were less common (3% each). The mean tumor diameter was 38 mm. Preoperative imaging showed cavernous sinus involvement in 39%, hyperostosis in 51%, and bone erosion in 24% ( Table 1 ) . Table 1 Clinical and Tumor Characteristics of Patients with SBM Variable n (%) Sex Female 72 (72.2) Male 29 (28.7) Age, yrs 52 (4–86) * Clinical presentation Proptosis 55 (54.5) Visual impairment 49 (48.5) Retroocular pain 35 (34.7) Headache 35 (34.7) Mass on face or neck 10 (9.9) Gait disturbance 10 (9.9) Seizures 9 (8.9) Peripheral weakness 7 (6.9) Anosmia 7 (6.9) Tumor characteristics Main extracranial extension Orbit 41 (40.6) Infratemporal fossa 18 (17.8) Paranasal sinuses 15 (14.9) Pterygopalatine fossa 12 (11.9) Ear canal 5 (5) Parapharyngeal space 4 (4) Neck 3 (3) Nasal cavity 3 (3) Radiologic characteristics Maximum diameter, mm 38 (18–144)** Cavernous sinus involvement 39 (38.6) Enhancement Homogeneous 74 (73.3) Heterogeneous 27 (26.7) Bony changes Hyperostosis 51 (50.5) Erosion 25 (24.7) Calcification 18 (17.8) En Plaque 21 (20.8) Histological features WHO grade Grade 1 73 (72.3) Grade 2 25 (24.7) Grade 3 3 (2.9) Ki-67 > 5% 47 (47.5) NF2 positive 10 (10) Brain invasion 16 (15.9) Posoperative complications Landriel-Ibanez system ¥, € 33 (32.6) Grade Ia 5 (4.9) Grade Ib 12 (11.8) Grade IIa 5 (4.9) Grade Iib 4 (3.9) Grade IIIa 5 (4.9) Grade IIIb 2 (1.9) Postoperative CN deficits 5 (4.9) Trochlear palsy 2 (1.9) Abducens palsy 2 (1.9) Facial palsy 1 (0.9) Adjuvant radiotherapy 18 (17.8) Volumetric-modulated arc therapy (VMAT) α 8 (7.9) Intensity-modulated radiotherapy (IMRT) £ 7 (6.9) Proton Therapy Ω 2 (1.9) External beam radiotherapy µ 1 (0.9) Outcomes Recurrence 41 (40.6) Death 17 (16.8) Time of latest follow-up, months 50 (78) ** Time to recurrence, months 33 (48) ** *Mean (Standard deviation); **Median (Range) ¥ Medical or surgically related complications within 30 days of surgery. Grade I (non-life-threatening, no invasive treatment; Ia: no medication, Ib: medication needed). Grade II requiring invasive procedures (IIa: local anesthesia, Iib: general anesthesia), Grade III involving life-threatening/organ failure ICU cases (IIIa: single organ, IIIb: multiple organs) and Grade IV (Death). € Grade Ia (non–life-threatening, no treatment): 5 metabolic alterations; Grade Ib (non–life-threatening, medication): 9 non-CNS infections, 2 adrenal insufficiency cases, 1 deep venous thrombosis; Grade IIa (invasive intervention, no anesthesia): 4 CSF leaks (lumbar drain), 1 epistaxis (embolization); Grade IIb (invasive intervention, general anesthesia): 1 epidural hematoma (surgical drainage), 3 CSF leaks (surgical repair); Grade IIIa (life-threatening, single-organ ICU): 4 seizures, 1 stroke; Grade IIIb (life-threatening, multi-organ ICU): 2 septic shock cases; Grade IV : none reported. α Median number of fractions: 30 (Range 27–30); Median dose: 57cGy (Range 48.6–60). £ Median number of fractions: 28 (Range 20–30); Median dose: 52.2cGy (Range 50–60). Ω Fractions 33–35, Dosage (62.4cGy – 65cGy). µ 30 Fractions, 54 cGy for total dose. Surgical Strategies, Complications and Outcomes The fronto-temporal craniotomy, with or without orbitozygomatic osteotomy (FT ± OZ), was the most common approach, used alone in 85% of Zone I and 73% of Zone II tumors, and combined with endonasal endoscopy in an additional 4% and 8% of cases ( Table 2 ) . SB reconstruction was required in 90% of cases and involved cranial, dural, and soft tissue components. Cranial reconstruction used implant materials (PEEK, titanium mesh, SYNPOR®, MEDPOR®) in 57% of zone I and 43% of zone II cases. In Zone 3 tumors, all patients who required cranial reconstruction were reconstructed with titanium mesh. All soft tissue reconstructions were autologous, including abdominal fat grafts, pedicled temporalis flaps, and anterolateral thigh (ALT) free flaps. Duroplasty was performed using autologous pericranium or fascia lata grafts and dural allografts ( Table 2 ) . GTR was achieved in 62.4% of cases ( Table 1 ) : 68% in zone I, 57% in zone II, and 59% in zone III. GTR was most frequently obtained with single FT + OZ in zone I (70%) and subtemporal-infratemporal approaches in zone II (83%) ( Table 2 ) . Combined approaches were not statistically significant predictors of GTR (aOR 0.28, 95% CI 0.16–1.08; p = 0.063). STR was more frequent in zone II tumors treated with FT + OZ (41%) (Table 2 ) . Table 2 Outcomes, Reconstruction, and Complications by Surgical Approach and Irish Zone Zone Approach GTR (%) Reconstruction Duraplasty Complications Composite soft-tissue Split calvarial Allo-skull implants Dura-allograft Dura-autograft CSF leak Wound infection I (n = 47) FrontoTemporal Craniotomy ± OZ Osteotomy (n = 40) 70% 3 (7.5) 1(2.5) 25 (63) 24 (60) 6(15) 2 (5) 3 (7.5) Transbasal (n = 3) 67% 0 (0) 0 (0) 0 (0) 1 (33.3) 1 (33.3) 1 (2.5) 0 (0) Endoscopic Endonasal (n = 1) 100% 0 (0) 0 (0) 0 (0) 0 (0) 1 (100) 0 (0) 0 (0) Combined OZ plus EETPA (n = 1) 100% 1 (100) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) Combined transbasal plus EEA (n = 1) 0% 0 (0) 0 (0) 1 (100) 1 (100) 0 (0) 0 (0) 0 (0) Combined FT plus EEA (n = 1) 0% 0 (0) 0 (0) 1 (100) 1 (100) 0 (0) 0 (0) 0 (0) II (n = 37) FrontoTemporal Craniotomy ± OZ Osteotomy (n = 27) 59% 1(3.7) 0 (0) 14 (52) 21 (77.8) 3 (11.1) 1 (3.7) 0 (0) Subtemporal–Infratemporal (n = 6) 83% 1 (16.7) 0 (0) 1 (16.7) 2 (33.3) 2 (33.3) 0 (0) 0 (0) Extended MiddleFossa (n = 1) 0% 0 (0) 0 (0) 0 (0) 1 (100) 0 (0) 0 (0) 0 (0) Combined FT + OZ plus EEA or EETPA (n = 3) 0% 0 (0) 0 (0) 1 (33.3) 2 (66.7) 1 (33.3) 0 (0) 0 (0) III (n = 17) Extended MiddleFossa (n = 1) 0% 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) Subtemporal–Infratemporal (n = 2) 50% 0 (0) 0 (0) 0 (0) 1 (50) 0 (0) 0 (0) 0 (0) Retrolabyrinthine (n = 1) 0% 1 (100) 0 (0) 1 (100) 0 (0) 0 (0) 1 (100) 0 (0) Retrosigmoid (n = 3) 100% 0 (0) 0 (0) 1 (33.3) 3 (100) 0 (0) 1 (33) 0 (0) Far Lateral (n = 7) 71% 1 (14.3) 0 (0) 1 (14.3) 5 (71.4) 1 (14.3) 2 (29) 0 (0) Combined Far lateral plus OZ (n = 2) 50% 1 (50) 0 (0) 0 (0) 2 (100) 1 (50) 0 (0) 0 (0) Combined Retrosigmoid plus OZ (n = 1) 0% 0 (0) 0 (0) 1 (100) 1 (100) 0 (0) 0 (0) 0 (0) Footnote : n = number of cases per approach; percentages in parentheses. GTR = gross total resection; CSF = cerebrospinal fluid; OZ = orbitozygomatic osteotomy. Composite soft-tissue flaps include pericranial and temporalis flaps. Duraplasty “allograft” comprises DuraGen® and AlloDerm®; “autograft” comprises fascia lata, abdominal-fat grafts, and free flaps. Wound-infection rates reflect any postoperative surgical-site infection. WHO grade 2 tumors were significantly associated with STR compared to grade 1 (aOR 2.87, 95% CI 1.03–7.99; p = 0.043), while grade 3 histology showed no correlation with resection extent ( p = 0.76). Prior radiation (aOR 6.77; p = 0.093) and tumors in zones II or III trended toward STR but were not statistically significant ( Table 3 ) . Table 3 Predictive Factors for Subtotal Resection Predictor aOR 95% CI p-value WHO grade2 3.06 1.13–8.57 0.029 WHO grade3 0.65 0.05–10.5 0.763 Combined approaches 0.81 0.16–1.28 0.163 Previous radiation 4.30 1.05–59.5 0.043 Irish Zone 2 1.76 0.66–4.71 0.256 Irish Zone 3 2.32 0.69–7.83 0.172 KPS (> 70) 8.73 1.91–33.4 0.011 Maximum diameter (35mm) 2.65 1.47–11.7 0.044 Tumor maximum diameter was dichotomized at 35 mm, based on optimal threshold determined by ROC analysis. KPS was dichotomized at > 70. aOR: adjusted Odds Ratio; CI: Confidence interval. Most postoperative complications were non-life-threatening (Grade I), including five Grade Ia events (metabolic disturbances) and twelve Grade Ib events (non-CNS infections, adrenal insufficiency, and deep vein thrombosis). CSF leaks (Grade II) occurred in 8% of patients: three in zone I, two in zone II, and three in zone III. In zone I, one leak followed a transbasal approach without reconstruction, and two followed FT + OZ approaches reconstructed with pedicled temporalis flaps, dural allografts, and PEEK cranioplasties. In zone II, leaks occurred after a transpetrosal approach reconstructed with titanium mesh and fat graft, and an FT + OZ approach reconstructed with a dural allograft and PEEK. In zone III, two leaks followed far-lateral approaches, and one occurred after a retrosigmoid approach, all reconstructed with dural allografts, fat grafts, and either fascia lata or titanium mesh ( Table 2 ). All CSF leaks were initially managed with lumbar drainage. One Zone III patient developed fungal meningitis, epidural abscess, and systemic infection (Grade III complication), requiring surgical repair with an anterolateral thigh (ALT) free flap. Another leak, associated with a Zone II tumor, was secondary to postoperative hydrocephalus and required treatment with a ventriculoperitoneal shunt. Post-operative adjuvant radiotherapy was administered to 18 patients, predominantly with volumetric modulated arc therapy (VMAT), with a median total dose of 57 Gy. Predictors of Tumor Control Rates and Overall Survival Tumor recurrence occurred in 41% of patients, with a median time to recurrence of 33 months (IQR 48) ( Table 1 ) . WHO Grade III tumors had the highest recurrence risk (HR 27.28; p = 0.003). STR significantly decreased PFS (HR 2.73; p = 0.014), as did cranial nerve dysfunction (HR 2.49; p = 0.025) and brain invasion (HR 2.99; p = 0.036). Omission of radiotherapy was associated with worse PFS in multivariate analysis (HR 3.57; p = 0.039) ( Table 4 ). WHO grade II and III tumors were associated with higher mortality (HR 10.52; p = 0.046 and HR 90.35; p = 0.002, respectively). STR and Simpson grade 3 resections significantly worsened OS (HR 5.72; p = 0.012 and HR 95.9; p = 0.003, respectively). Cavernous sinus involvement (HR 4.36, p = 0.017) and brain invasion (HR 5.47, p = 0.031) also correlated with worse OS. While adjuvant radiotherapy was associated with decreased OS in univariate analysis (HR 3.22; p = 0.035), multivariate analysis revealed a protective effect when adjusted for confounders (HR 0.15; p = 0.029) ( Table 4 ) . Table 4 Multivariable and Univariable Cox Regression for Recurrence-Free and Overall Survival Variable Level Recurrence-Free Survival Overall Survival HR (Univariate) HR (Multivariate) HR (Univariate) HR (Multivariate) Age > 50 years - - - - < 50 years 1.49 (0.78–2.84, p = 0.223) 1.05 (0.45–2.45, p = 0.914) 0.45 (0.17–1.22, p = 0.118) 0.27 (0.06–1.13, p = 0.074) Sex Female - - - - Male 2.64 (1.41–4.97, p = 0.003) 1.96 (0.97–3.96, p = 0.059) 2.57 (0.93–7.13, p = 0.069) 3.72 (1.06–13.07, p = 0.040) Cranial-nerve alteration No - - - - Yes 3.04 (1.52–6.10, p = 0.002) 2.49 (1.12–5.53, p = 0.025) 1.03 (0.40–2.69, p = 0.945) 1.98 (0.50–7.76, p = 0.328) Seizures No - - - - Yes 0.88 (0.31–2.47, p = 0.802) 0.11 (0.02–0.54, p = 0.006) 3.23 (1.16–9.01, p = 0.025) 4.36 (1.29–14.71, p = 0.017) Enhancement Homogeneous - - - - Heterogeneous 2.03 (1.07–3.87, p = 0.031) 1.35 (0.61–3.03, p = 0.460) 2.62 (0.92–7.47, p = 0.072) 10.52 (1.01-106.38, p = 0.046) Cavernous-sinus involvement No - - 13.57 (2.68–68.72, p = 0.002) 90.35 (4.98-1640.81, p = 0.002) Yes 1.56 (0.80–3.02, p = 0,190) 0.76 (0.32–1.82, p = 0.542) - - WHO grade Grade 1 - - - - Grade 2 1.72 (0.88–3.37, p = 0.115) 2.21 (0.70–6.91, p = 0.174) 1.92 (0.69–5.30, p = 0.210) 1.65 (0.20-13.92, p = 0.645) Grade 3 7.61 (1.65–35.04, p = 0.009) 27.28 (3.20-232.77, p = 0.003) 2.69 (0.96–7.52, p = 0.059) 5.47 (1.17–25.59, p = 0.031) Ki-67 index 5% 1.96 (1.04–3.71, p = 0.037) 1.84 (0.70–4.82, p = 0.213) 1.66 (0.62–4.41, p = 0.312) 5.72 (1.47–22.26, p = 0.012) Brain invasion No - - - - Yes 2.68 (1.21–5.96, p = 0.015) 2.99 (1.07–8.31, p = 0.036) 12.02 (1.11-130.39, p = 0.041) 42.31 (1.75-1023.95, p = 0.021) EOR Yes - - 10.76 (1.06-108.75, p = 0.044) 95.90 (4.51-2039.06, p = 0.003) No 0.63 (0.27–1.45, p = 0.274) 3.57 (1.07–11.94, p = 0.039) 1.82 (0.10-33.38, p = 0.688) 19.52 (0.55-689.24, p = 0.102) Simpson grade Gross Total - - - - Subtotal 1.78 (0.95–3.32, p = 0.070) 2.73 (1.23–6.06, p = 0.014) 3.22 (1.09–9.50, p = 0.035) 0.15 (0.03–0.82, p = 0.029) Simpson 1 - - - - Simpson 2 5.64 (1.86–17.15, p = 0.002) 3.90 (1.10-13.89, p = 0.035) 0.74 (0.28–1.96, p = 0.540) 0.09 (0.02–0.54, p = 0.008) Adjuvant RT Simpson 3 4.46 (1.49–13.29, p = 0.007) 5.81 (1.68–20.04, p = 0.005) - - Simpson 4 13.93 (3.34–58.19, p < 0.001) 12.36 (2.04–74.96, p = 0.006) 0.45 (0.17–1.22, p = 0.118) 0.27 (0.06–1.13, p = 0.074) Recurrence No – – - - Yes – – 2.57 (0.93–7.13, p = 0.069) 3.72 (1.06–13.07, p = 0.040) Footnote : HR = hazard ratio; CI = confidence interval; EOR = extent of resection (GTR = gross total resection; STR = subtotal resection); RT = adjuvant radiotherapy; WHO = World Health Organization; Simpson grade refers to surgical resection scale (1–4). Models adjusted for all listed covariates; likelihood-ratio p < 0.001 for RFS and p = 0.004 for OS. Discussion SBM-EE represents a unique subset, with recurrence rates of up to 35% and 10% at 5 years, even after GTR.[ 8 ] To our knowledge, this is the first study exploring differences in surgical approaches, tumor location, extension patterns, extent of resection (EOR), recurrence, reconstruction techniques, and associated complication rates. Following the three sequential stages of SBM surgery¹³—exposure, subarachnoid dissection, and reconstruction—we selected the most appropriate approaches to optimize EOR and enable comprehensive SB reconstruction. Within this framework, FT ± OZ, transbasal, endonasal endoscopic, and combined approaches have demonstrated favorable EOR rates, cosmetic outcomes, and low morbidity for craniofacial SBM (zone I) [ 4 , 13 – 15 ]. When extracranial invasion occurs, tumors—primarily olfactory groove, planum sphenoidale, cribriform plate, and clival meningiomas—often extend into the paranasal sinuses, nasal cavity, or orbit [ 13 ]. Consequently, most zone I lesions in our cohort were treated via FT ± OZ, achieving a GTR in 69%, compared to 100% with EEA and 50% with the transbasal approach. These results align with previous series reporting GTR rates around 60% for zone I SBM-EE [ 14 ]. Although EEA is often favored for achieving higher EOR in zone I SBM-EE, its ability to address tumors with significant lateral or anterior extension—and to preserve olfactory function—is limited. In such cases, the transbasal approach remains preferable due to better olfactory preservation, despite generally lower GTR rates than EEA [ 15 , 16 ]. Sphenoorbital meningiomas (SOMs) represent a distinct SBM-EE subtype, classified as zone I or II based on dominant tumor volume [ 9 , 17 ]. While transorbital neuroendoscopic (TONES) approaches, combined with lateral orbitotomy, can achieve GTR in SOM, their effectiveness decreases when the pathology extends into the middle third of the sphenoid wing, the temporal floor, or the infratemporal fossa [ 18 ]. In such cases, FT + OZ combined with subtemporal-infratemporal approaches provides more direct access, facilitating complete tumor resection and comprehensive SB reconstruction. Kong et al. [ 18 ] reported GTR rates of 51% in a series where 68% of tumors exhibited extracranial extension treated through a TONES approach. In contrast, FT combined with subtemporal approaches has achieved a GTR of 34%, primarily due to residual tumor at the orbital apex [ 17 ]. In our cohort, lesions located in zone I and treated with FT ± OZ achieved a GTR rate of 70%, and 59% in zone II lesions, whereas when a subtemporal-infratemporal approach was incorporated in the latter, the GTR rate increased to 83%. Anterolateral (zone II) SBM, arising from the greater wing of the sphenoid, sphenoidal ridge, and cavernous sinus, poses unique challenges due to its tendency to extend transcranially into the infratemporal and pterygopalatine fossae [ 4 , 13 ]. FT + OZ and subtemporal-infratemporal approaches remain the approaches of choice for these anterolateral tumors, along with or without extended middle fossa approach (i.e., transpetrosal) [ 19 – 21 ]. Furthermore, they allow access to the maxillary sinus by drilling the anterior limit of the pterygopalatine fossa; to the parapharyngeal space after laterally retracting the medial pterygoid muscle; and to the sphenoid sinus by drilling the base of the pterygoid process to perform a lateral sphenoidectomy [ 4 , 22 , 23 ]. Nakao et al [ 4 ], reported 90% GTR rates in similar tumors using these approaches. Similarly, Pieper and Al-Mefty [ 22 ], reported a GTR rate of 78% of zone II SBM operated through FT + OZ approach. In our cohort, GTR was achieved in 59% of zone II cases treated with FT ± OZ and 83% of those managed with subtemporal-infratemporal approaches. Although the subtemporal-infratemporal approach seemed to provide an additional access to achieve complete resection, we found that cavernous sinus involvement, observed in 38.6% of cases, was associated with reduced likelihood of GTR. This underscores that although the appropriate approach selection remains a cornerstone to achieve GTR, STRs are pursued not due to access limitations but for patient safety in the context of a benign entity. Posterolateral (zone III) SBM-EE involving the petrous bone, ear canal, the parapharyngeal space, and upper cervical soft tissue was approached via subtemporal-infratemporal, extended middle fossa, presigmoid (e.g., retrolabyrinthine), far-lateral, and retrosigmoid routes [ 24 – 26 ]. Our cohort demonstrated GTR rates of 71% after far lateral approaches and 100% with retrosigmoid approaches. These findings are consistent with previous reports suggesting that posterolateral foramen magnum meningiomas may offer higher GTR rates than their anterolateral counterparts, likely due to more straightforward surgical access [ 27 ]. Regarding the third stage of SBM surgery, skull base reconstruction techniques ranged from simple duroplasties to comprehensive reconstructions involving the dura mater, bone (due to resection aiming to achieve a lower Simpson grade), and soft tissue. Dural reconstruction is typically performed using autologous fascial, muscle, or fat grafts and is generally more straightforward in anterior SBM-EE (Zone I) cases approached via a transbasal route, compared to reconstructions in zones II and III [ 28 ]. In zone I SBM-EE, a defect of 1.5 cm has been described as the threshold between the defects that can be reconstructed with autologous fascia, muscle, and fat, and those requiring combined techniques, including osseous reconstruction with autogenous bone, titanium mesh, or PEEK cranioplasties [ 28 ]. Autologous grafts of fat and fascia are the most commonly described to address SB defects, with the transposition of a pedicled temporalis muscle flap recommended when a watertight closure is not possible [ 22 ]. In our series, comprehensive SB reconstruction was performed in cases where primary watertight closure was not feasible, a highly deformative defect was present, or when significant dead space remained. However, we found a significant difference in CSF leak rates by tumor location, with zone III SBM-EE demonstrating the highest rate (27%) compared to zone I (6.4%) and zone II (2.7%). Wound infections occurred in 2.9% of patients (3 of 101), all of whom had undergone an FT + OZ approach, and one patient required debridement (0.9%). This contrasts with the prior series of SBM-EE, where surgical debridement was 10% [ 4 ]. These findings highlight the importance of meticulous skull base reconstruction and multilayer closure techniques in minimizing postoperative complications, particularly in cases requiring complex craniofacial resections and adjuvant therapies. Incomplete resection has been associated with skull base location, bone/brain invasion, and higher WHO grade [ 29 , 30 ]. In our cohort, STR was significantly associated with WHO grade 2 histology ( p = 0.029), prior radiation therapy ( p = 0.043), and tumors larger than 35 mm ( p = 0.044), although tumor zone did not predict STR. Similarly, WHO grade 3, brain invasion, and lack of adjuvant radiation therapy were associated with higher recurrence rates. Notably, increasing Simpson grade correlated with progressively greater recurrence risk, with hazard ratios of 3.9, 5.81, and 12.36 for Simpson grades II, III, and IV, respectively. Our results highlight the need for aggressive but anatomically mindful resection strategies and robust skull base reconstruction to optimize outcomes in SBM-EE. Limitations This study is limited by its retrospective design and single institution setting, which may introduce selection bias and limit generalizability. The long study period may also reflect changes in surgical techniques and imaging modalities over time. Additionally, although the Irish classification was used to standardize tumor location, some overlap between zones may persist in multicompartmental tumors. Conclusion SBM-EEs present unique surgical challenges, with EOR, WHO grade, cavernous sinus invasion, and brain invasion identified as key predictors of recurrence and survival. Tailored surgical approaches—such as FT ± OZ and subtemporal-infratemporal extensions—optimize access, but achieving GTR remains difficult in multicompartmental tumors. Comprehensive skull base reconstruction is essential, particularly to minimize postoperative CSF leak rates, which were highest in Zone III tumors. Despite the surgical complexity, wound complication rates remained low. Individualized planning based on tumor location and extension is critical to balance oncological control with functional outcomes. Future refinements incorporating vascular supply patterns may further improve surgical strategy selection and patient outcomes. Declarations Funding: The authors declare that no funds, grants, or other support were received during the preparation of this manuscript. Competing Interests: The authors have no relevant financial or non-financial interests to disclose. Author Contributions: All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Juan Pablo Zuluaga-García, Esteban Ramirez-Ferrer and Sophie F. Peteers. The first draft of the manuscript was written by Juan Pablo Zuluaga-García, Esteban Ramirez-Ferrer, Shaan Raza, Franco DeMonte and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. Data Availability: The datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request. Ethics approval: This is an observational study. Institutional Review Board (IRB) protocol was approved, including Research Ethics Committee of University of Texas MD Anderson Cancer Center, and has confirmed that no ethical approval is required. Informed consent: Informed consent was waived for this study after IRB approval. Consent to publish: The authors affirm that human research participants provided informed consent for publication of the images in Figure(1) 1a, 1b and 1c. References McGovern SL, Aldape KD, Munsell MF, et al (2010) A comparison of World Health Organization tumor grades at recurrence in patients with non–skull base and skull base meningiomas: Clinical article. J Neurosurg 112:925–933. https://doi.org/10.3171/2009.9.JNS09617 Westphal M, Saladino A, Tatagiba M (2023) Skull Base Meningiomas. In: Zadeh G, Goldbrunner R, Krischek B, Nassiri F (eds) Biological and Clinical Landscape of Meningiomas. Springer International Publishing, Cham, pp 47–68 Mansouri A, Klironomos G, Taslimi S, et al (2016) Surgically resected skull base meningiomas demonstrate a divergent postoperative recurrence pattern compared with non–skull base meningiomas. J Neurosurg 125:431–440. https://doi.org/10.3171/2015.7.JNS15546 Nakao N, Ohkawa T, Miki J, et al (2010) Surgical treatment and outcome of skull base meningiomas with extracranial extensions. Clin Neurol Neurosurg 112:40–46. https://doi.org/10.1016/j.clineuro.2009.10.003 Liu H, Qian H, Li X, et al (2020) Clinial Features, Individualized Treatment and Long-Term Surgical Outcomes of Skull Base Meningiomas With Extracranial Extensions. Front Oncol 10:1054. https://doi.org/10.3389/fonc.2020.01054 Gabriel PJ, Kohli G, Hsueh WD, et al (2020) Efficacy of simultaneous pericranial and nasoseptal “double flap” reconstruction of anterior skull base defects after combined transbasal and endoscopic endonasal approaches. Acta Neurochir (Wien) 162:641–647. https://doi.org/10.1007/s00701-019-04155-1 Fraser S, Gardner PA, Koutourousiou M, et al (2018) Risk factors associated with postoperative cerebrospinal fluid leak after endoscopic endonasal skull base surgery. 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Stat Med 21:2409–2419. https://doi.org/10.1002/sim.1047 RStudio Team RStudio: Integrated Development for R Leonetti JP, Reichman OH, Smith PG, et al (1990) Meningiomas of the lateral skull base: Neurotologic manifestations and patterns of recurrence. Otolaryngol Neck Surg 103:972–980. https://doi.org/10.1177/019459989010300615 Peto I, Monsour M, Piper K, et al (2023) Nasofrontal meningiomas: retrospective series and review of literature. Neurosurg Rev 46:158. https://doi.org/10.1007/s10143-023-02053-w Ottenhausen M, Rumalla K, Alalade AF, et al (2018) Decision-making algorithm for minimally invasive approaches to anterior skull base meningiomas. Neurosurg Focus 44:E7. https://doi.org/10.3171/2018.1.FOCUS17734 Liu JK, Silva NA, Sevak IA, Eloy JA (2018) Transbasal versus endoscopic endonasal versus combined approaches for olfactory groove meningiomas: importance of approach selection. Neurosurg Focus 44:E8. https://doi.org/10.3171/2018.1.FOCUS17722 Kiyofuji S, Casabella AM, Graffeo CS, et al (2020) Sphenoorbital meningioma: a unique skull base tumor. Surgical technique and results. J Neurosurg 133:1044–1051. https://doi.org/10.3171/2019.6.JNS191158 Kong D-S, Kim YH, Hong C-K (2021) Optimal indications and limitations of endoscopic transorbital superior eyelid surgery for spheno-orbital meningiomas. J Neurosurg 134:1472–1479. https://doi.org/10.3171/2020.3.JNS20297 Bernardo A, Evins AI (2023) Anterolateral Routes to the Skull Base—The Frontotemporal Approaches and Exposure of the Sellar and Parasellar Regions. World Neurosurg 172:131–145. https://doi.org/10.1016/j.wneu.2022.11.055 Soleman J, Leiggener C, Schlaeppi A-J, et al (2016) The Extended Subfrontal and Fronto-Orbito-Zygomatic Approach in Skull Base Meningioma Surgery: Clinical, Radiologic, and Cosmetic Outcome. J Craniofac Surg 27:433–440. https://doi.org/10.1097/SCS.0000000000002368 Bir SC, Maiti T, Konar S, Nanda A (2017) Comparison of the Surgical Outcome of Pterional and Frontotemporal-Orbitozygomatic Approaches and Determination of Predictors of Recurrence for Sphenoid Wing Meningiomas. World Neurosurg 99:308–319. https://doi.org/10.1016/j.wneu.2016.10.057 Pieper DR, Al-Mefty O (1999) Management of Intracranial Meningiomas Secondarily Involving the Infratemporal Fossa: Radiographic Characteristics, Pattern of Tumor Invasion, and Surgical Implications. Neurosurgery 45:231–237. https://doi.org/10.1097/00006123-199908000-00005 Sun DQ, Menezes AH, Howard MA, et al (2018) Surgical Management of Tumors Involving Meckel’s Cave and Cavernous Sinus: Role of an Extended Middle Fossa and Lateral Sphenoidectomy Approach. Otol Neurotol 39:82–91. https://doi.org/10.1097/MAO.0000000000001602 Hoz SS, Palmisciano P, Albairmani SS, et al (2023) A proposed classification system for presigmoid approaches: a scoping review. J Neurosurg 139:965–971. https://doi.org/10.3171/2023.2.JNS222227 Tummala RP, Coscarella E, Morcos JJ (2005) Transpetrosal approaches to the posterior fossa. Neurosurg Focus 19:1–9. https://doi.org/10.3171/foc.2005.19.2.7 Bernardo A, Evins AI (2023) Posterolateral Routes to the Skull Base, Craniocervical Junction, and Jugular Foramen—The Far Lateral Transcondylar Approach and Combined Transpetrosal Transcervical Approaches. World Neurosurg 172:163–174. https://doi.org/10.1016/j.wneu.2022.11.053 Paun L, Gondar R, Borrelli P, Meling TR (2021) Foramen magnum meningiomas: a systematic review and meta-analysis. Neurosurg Rev 44:2583–2596. https://doi.org/10.1007/s10143-021-01478-5 He J, Lu J, Zhang F, et al (2021) The Treatment Strategy for Skull Base Reconstruction for Anterior Cranial Fossa Intra- and Extracranial Tumors. J Craniofac Surg 32:1673–1678. https://doi.org/10.1097/SCS.0000000000007244 Lemée J-M, Corniola MV, Da Broi M, et al (2019) Extent of Resection in Meningioma: Predictive Factors and Clinical Implications. Sci Rep 9:5944. https://doi.org/10.1038/s41598-019-42451-z Kim D, Niemierko A, Hwang WL, et al (2018) Histopathological prognostic factors of recurrence following definitive therapy for atypical and malignant meningiomas. J Neurosurg 128:1123–1132. https://doi.org/10.3171/2016.11.JNS16913 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 19 Jun, 2025 Read the published version in Journal of Neuro-Oncology → Version 1 posted Editorial decision: Revision requested 17 May, 2025 Reviews received at journal 15 May, 2025 Reviews received at journal 12 May, 2025 Reviewers agreed at journal 07 May, 2025 Reviewers agreed at journal 06 May, 2025 Reviewers agreed at journal 05 May, 2025 Reviewers invited by journal 05 May, 2025 Editor assigned by journal 05 May, 2025 Submission checks completed at journal 05 May, 2025 First submitted to journal 04 May, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6590546","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":453426365,"identity":"07fdfc93-706c-49e5-927c-c2b799253d78","order_by":0,"name":"Juan P. Zuluaga-García","email":"","orcid":"","institution":"The University of Texas MD Anderson Cancer Center","correspondingAuthor":false,"prefix":"","firstName":"Juan","middleName":"P.","lastName":"Zuluaga-García","suffix":""},{"id":453426366,"identity":"a69ac46f-dfd7-41d4-80a5-c48d9bb75afc","order_by":1,"name":"Esteban Ramírez-Ferrer","email":"","orcid":"","institution":"The University of Texas MD Anderson Cancer Center","correspondingAuthor":false,"prefix":"","firstName":"Esteban","middleName":"","lastName":"Ramírez-Ferrer","suffix":""},{"id":453426367,"identity":"175f0575-dc55-461d-a48a-9f39508af030","order_by":2,"name":"Sophie F. Peeters","email":"","orcid":"","institution":"The University of Texas MD Anderson Cancer Center","correspondingAuthor":false,"prefix":"","firstName":"Sophie","middleName":"F.","lastName":"Peeters","suffix":""},{"id":453426368,"identity":"1b4a55d4-93f0-4a27-bf9d-485ab3dfdceb","order_by":3,"name":"Franco DeMonte","email":"","orcid":"","institution":"The University of Texas MD Anderson Cancer Center","correspondingAuthor":false,"prefix":"","firstName":"Franco","middleName":"","lastName":"DeMonte","suffix":""},{"id":453426369,"identity":"c8d83c94-98c3-4d59-8ffd-2022cd1973b9","order_by":4,"name":"Shaan M. Raza","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA40lEQVRIiWNgGAWjYPACGwaGAwwMEqRoSSNdy2EStMhPO/vw44+a89F8x88evPFxT52cOQPzsY9f8GgxuJ1uLCFx7HbuzDN5yZYznh02tmxgS54tg0+LdBqDhAHb7dwNB3LMpHkOHEjccIDHmBmfE+VnpzH/SPh3LnfD+Tdm0n8O1BHWwnA7jU3iYNuB3A03gLYwHGAGa2H8gNcvaWyWjX3JuTNvvDG27Dlw2NjgMFsyMz5LQA67+eObXW7f+RzDGz8O1MkZHG8+zPgDnx5MALSCmYc0LUBAqi2jYBSMglEwvAEAR2VSud7WzssAAAAASUVORK5CYII=","orcid":"","institution":"The University of Texas MD Anderson Cancer Center","correspondingAuthor":true,"prefix":"","firstName":"Shaan","middleName":"M.","lastName":"Raza","suffix":""}],"badges":[],"createdAt":"2025-05-05 00:53:15","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6590546/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6590546/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s11060-025-05111-z","type":"published","date":"2025-06-19T15:57:51+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":82278823,"identity":"59da7224-b2c5-4c0e-acf2-c7be7aba8ba8","added_by":"auto","created_at":"2025-05-08 14:57:40","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":584726,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eSBM-EE location defined according to Irish classification.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFootnote: \u003c/em\u003eA. Anterior and middle fossa with extension primarily to nasal cavity, paranasal sinuses and orbit, Irish zone I. B. Right lesser wing sphenoid meningioma with extension to infratemporal and pterygopalatine fossae, Irish zone II. C. Left petrous bone and CPA meningioma compromising the left carotid canal, Irish zone III.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-6590546/v1/ed3c5484c1521170c3298d0f.png"},{"id":85231395,"identity":"b0c10ea9-1379-4e33-ad44-8aee936a312b","added_by":"auto","created_at":"2025-06-23 16:07:10","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2258524,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6590546/v1/75d9740e-7939-43c3-a6c1-5afae693874e.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Management of Skull Base Meningiomas with Extracranial Extension: Resection, Recurrence, and Prognostic Factors","fulltext":[{"header":"Introduction","content":"\u003cp\u003eSkull-base meningiomas (SBMs) represent a distinct subgroup of intracranial meningiomas and are often associated with a more aggressive clinical course despite their typically benign histology [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Their proximity to neurovascular structures and frequent extension into adjacent compartments may limit the extent of resection (EOR), often requiring complex surgical approaches [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Additionally, recurrence risk in SBM follows a prolonged course, with recurrence rates plateauing beyond the 100 months of follow-up [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSBMs occasionally extend into extracranial compartments, such as the infratemporal fossa, pterygopalatine fossa, orbit, nasal cavity, and paranasal sinuses, through anatomical skull base (SB) foramina or through bone erosion [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. This transcompartmental behavior often requires a multidisciplinary approach to achieve safe maximal resection and effective reconstruction while minimizing complications [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. However, such interventions are associated with a higher risk of postoperative complications, including cerebrospinal fluid (CSF) leakage and flap necrosis, particularly in the context of planned adjuvant radiation therapy [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePublished series report gross total resection (GTR) rates for SBMs with extracranial extension (SBM-EE) ranging from 55\u0026ndash;62.3%, with postoperative complication rates approaching 20% [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Despite these tumors being predominantly WHO grade 1, recurrence rates as high as 35% at five years have been documented [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. While prior studies have evaluated the extent of resection (EOR) in SBM-EE, data remain limited regarding the correlation between tumor location, including patterns of extracranial involvement, and recurrence rates, surgical approaches, reconstruction techniques, and outcomes, particularly complications related to SB reconstruction. This study aims to retrospectively assess clinical, radiographic, surgical, pathological, and adjuvant therapy variables associated with outcomes in this anatomically and surgically complex subset of transcranial tumors. The analysis seeks to provide meaningful insights into surgical planning, prognostication, and support the development of multidisciplinary treatment strategies specifically tailored to SBM-EE.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and patient data\u003c/h2\u003e \u003cp\u003eA retrospective cohort study was conducted, including all patients diagnosed with SBM exhibiting transcranial invasion who underwent surgical resection at our institution between January 1993 and August 2024. Histopathological diagnoses were confirmed using the 2007, 2016, or 2021 WHO criteria and reclassified according to the 2021 WHO classification. Institutional Review Board approval was obtained, and data were managed according to ethical standards.\u003c/p\u003e \u003cp\u003eCollected variables included demographics (age, sex) and clinical manifestations (e.g., visual impairment, cranial nerve dysfunction). Tumor location was classified according to the Irish et al. system[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]: Zone I includes tumors originating from the anterior skull base, sella, or clivus with extension into the paranasal sinuses, orbit, or anterolateral foramen magnum (anterior to dentate ligaments); Zone II involves lateral middle fossa lesions extending into the infratemporal or pterygopalatine fossae; and Zone III includes tumors in the posterolateral middle or posterior fossa involving the petrous temporal bone with extension into the ear canal, neck, or posterolateral foramen magnum \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Tumors spanning multiple zones were classified according to the predominant tumor volume. Additional data collected included tumor dimensions, extracranial extension, radiographic and histopathological features (WHO grade, Ki-67 index), EOR, Simpson grade, surgical approach, and complications.\u003c/p\u003e \u003cp\u003eAdjuvant radiotherapy data, including delivery method and total dose, were recorded. Outcomes were assessed based on recurrence, overall survival (OS), progression-free survival (PFS), and 30-day postoperative complications. Postoperative complications were categorized using the Landriel-Ib\u0026aacute;\u0026ntilde;ez system [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]: Grade I (non-life-threatening, no invasive procedures), Grade II (requiring invasive management), Grade III (life-threatening, ICU treatment), and Grade IV (death due to complications). Recurrence was defined as radiographic tumor progression.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eData were analyzed using descriptive statistics. Depending on distribution, continuous variables were reported as means with standard deviations or analyzed with t-tests or Mann-Whitney U tests. Categorical variables were reported as frequencies and percentages and compared using chi-square tests. One-way ANOVA with Tukey\u0026rsquo;s post-hoc tests was used to compare subgroup medians.\u003c/p\u003e \u003cp\u003eKaplan\u0026ndash;Meier curves estimated PFS and OS, with group differences assessed using the log-rank test. PFS was stratified by treatment modality and tumor characteristics, including radiographic features, cavernous sinus invasion, brain invasion, and proliferation index. Univariable Cox proportional hazards models identified potential prognostic factors for PFS and OS; variables with p\u0026thinsp;\u0026lt;\u0026thinsp;0.20 were included in multivariable models using stepwise backward elimination. Hazard ratios (HRs) and 95% confidence intervals (CIs) were reported.\u003c/p\u003e \u003cp\u003eFor predictors of EOR with low event counts, Firth\u0026rsquo;s bias reduction logistic regression [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] was applied, including variables such as prior radiation, Irish zone, tumor diameter, and histological grade. Model significance was determined using the likelihood ratio test, with p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 considered statistically significant. Analyses and data visualizations were conducted using RStudio (version 4.4.2) [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003ePatient and Tumor Characteristics\u003c/h2\u003e \u003cp\u003eA total of 101 patients were included \u003cb\u003e(\u003c/b\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e. The most common clinical presentation was proptosis (55%), followed by visual impairment (49%) and retroocular pain (35%). Tumors were primarily located in zone I (47%), then zone II (36%), and zone III (18%). Frequent extracranial extension sites included the orbit (41%) and infratemporal fossa (18%), while nasal cavity and neck soft tissue involvement were less common (3% each). The mean tumor diameter was 38 mm. Preoperative imaging showed cavernous sinus involvement in 39%, hyperostosis in 51%, and bone erosion in 24% \u003cb\u003e(\u003c/b\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eClinical and Tumor Characteristics of Patients with SBM\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"1\" nameend=\"c3\" namest=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c3\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e72 (72.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29 (28.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, yrs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e52 (4\u0026ndash;86)\u0026nbsp;*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c3\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eClinical presentation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c3\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProptosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e55 (54.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c3\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVisual impairment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e49 (48.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c3\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRetroocular pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35 (34.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c3\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHeadache\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35 (34.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c3\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMass on face or neck\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (9.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c3\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGait disturbance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (9.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c3\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSeizures\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (8.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c3\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePeripheral weakness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (6.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c3\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnosmia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (6.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c3\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTumor characteristics\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c3\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMain extracranial extension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c3\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOrbit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41 (40.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c3\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInfratemporal fossa\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18 (17.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c3\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParanasal sinuses\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 (14.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c3\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePterygopalatine fossa\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (11.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c3\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEar canal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c3\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParapharyngeal space\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c3\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeck\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c3\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNasal cavity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c3\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRadiologic characteristics\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c3\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMaximum diameter, mm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38 (18\u0026ndash;144)**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c3\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCavernous sinus involvement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e39 (38.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c3\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEnhancement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c3\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHomogeneous\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e74 (73.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c3\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHeterogeneous\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27 (26.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c3\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBony changes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c3\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHyperostosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e51 (50.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c3\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eErosion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25 (24.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c3\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCalcification\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18 (17.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c3\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEn Plaque\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21 (20.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c3\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHistological features\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c3\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWHO grade\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c3\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrade 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e73 (72.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c3\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrade 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25 (24.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c3\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrade 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (2.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c3\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKi-67\u0026thinsp;\u0026gt;\u0026thinsp;5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e47 (47.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c3\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNF2 positive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c3\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBrain invasion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 (15.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c3\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePosoperative complications\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c3\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLandriel-Ibanez system\u003csup\u003e\u0026yen;, \u0026euro;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33 (32.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c3\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrade Ia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (4.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c3\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrade Ib\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (11.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c3\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrade IIa\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (4.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c3\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrade Iib\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (3.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c3\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrade IIIa\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (4.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c3\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrade IIIb\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (1.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c3\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePostoperative CN deficits\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (4.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c3\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTrochlear palsy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (1.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c3\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbducens palsy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (1.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c3\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFacial palsy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c3\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAdjuvant radiotherapy\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18 (17.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c3\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVolumetric-modulated arc therapy (VMAT)\u003csup\u003eα\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (7.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c3\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntensity-modulated radiotherapy (IMRT) \u003csup\u003e\u003cb\u003e\u0026pound;\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (6.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c3\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProton Therapy\u003csup\u003eΩ\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (1.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c3\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExternal beam radiotherapy\u003csup\u003e\u0026micro;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c3\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOutcomes\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c3\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRecurrence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41 (40.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c3\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDeath\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17 (16.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c3\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime of latest follow-up, months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50 (78) **\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c3\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime to recurrence, months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33 (48) **\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c3\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e*Mean (Standard deviation); **Median (Range)\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003csup\u003e\u0026yen;\u003c/sup\u003e Medical or surgically related complications within 30 days of surgery. Grade I (non-life-threatening, no invasive treatment; Ia: no medication, Ib: medication needed). Grade II requiring invasive procedures (IIa: local anesthesia, Iib: general anesthesia), Grade III involving life-threatening/organ failure ICU cases (IIIa: single organ, IIIb: multiple organs) and Grade IV (Death).\u003c/p\u003e \u003cp\u003e \u003csup\u003e\u0026euro;\u003c/sup\u003e \u003cem\u003eGrade Ia\u003c/em\u003e (non\u0026ndash;life-threatening, no treatment): 5 metabolic alterations; \u003cem\u003eGrade Ib\u003c/em\u003e (non\u0026ndash;life-threatening, medication): 9 non-CNS infections, 2 adrenal insufficiency cases, 1 deep venous thrombosis; \u003cem\u003eGrade IIa\u003c/em\u003e (invasive intervention, no anesthesia): 4 CSF leaks (lumbar drain), 1 epistaxis (embolization); \u003cem\u003eGrade IIb\u003c/em\u003e (invasive intervention, general anesthesia): 1 epidural hematoma (surgical drainage), 3 CSF leaks (surgical repair); \u003cem\u003eGrade IIIa\u003c/em\u003e (life-threatening, single-organ ICU): 4 seizures, 1 stroke; \u003cem\u003eGrade IIIb\u003c/em\u003e (life-threatening, multi-organ ICU): 2 septic shock cases; \u003cem\u003eGrade IV\u003c/em\u003e: none reported.\u003c/p\u003e \u003cp\u003e \u003csup\u003e \u003cb\u003eα\u003c/b\u003e \u003c/sup\u003e Median number of fractions: 30 (Range 27\u0026ndash;30); Median dose: 57cGy (Range 48.6\u0026ndash;60).\u003c/p\u003e \u003cp\u003e \u003csup\u003e \u003cb\u003e\u0026pound;\u003c/b\u003e \u003c/sup\u003e Median number of fractions: 28 (Range 20\u0026ndash;30); Median dose: 52.2cGy (Range 50\u0026ndash;60).\u003c/p\u003e \u003cp\u003e \u003csup\u003eΩ\u003c/sup\u003e Fractions 33\u0026ndash;35, Dosage (62.4cGy \u0026ndash; 65cGy).\u003c/p\u003e \u003cp\u003e \u003csup\u003e \u003cb\u003e\u0026micro;\u003c/b\u003e \u003c/sup\u003e 30 Fractions, 54 cGy for total dose.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSurgical Strategies, Complications and Outcomes\u003c/h3\u003e\n\u003cp\u003eThe fronto-temporal craniotomy, with or without orbitozygomatic osteotomy (FT\u0026thinsp;\u0026plusmn;\u0026thinsp;OZ), was the most common approach, used alone in 85% of Zone I and 73% of Zone II tumors, and combined with endonasal endoscopy in an additional 4% and 8% of cases \u003cb\u003e(\u003c/b\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e. SB reconstruction was required in 90% of cases and involved cranial, dural, and soft tissue components. Cranial reconstruction used implant materials (PEEK, titanium mesh, SYNPOR\u0026reg;, MEDPOR\u0026reg;) in 57% of zone I and 43% of zone II cases. In Zone 3 tumors, all patients who required cranial reconstruction were reconstructed with titanium mesh. All soft tissue reconstructions were autologous, including abdominal fat grafts, pedicled temporalis flaps, and anterolateral thigh (ALT) free flaps. Duroplasty was performed using autologous pericranium or fascia lata grafts and dural allografts \u003cb\u003e(\u003c/b\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e.\u003c/p\u003e \u003cp\u003eGTR was achieved in 62.4% of cases \u003cb\u003e(\u003c/b\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e: 68% in zone I, 57% in zone II, and 59% in zone III. GTR was most frequently obtained with single FT\u0026thinsp;+\u0026thinsp;OZ in zone I (70%) and subtemporal-infratemporal approaches in zone II (83%) \u003cb\u003e(\u003c/b\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e. Combined approaches were not statistically significant predictors of GTR (aOR 0.28, 95% CI 0.16\u0026ndash;1.08; p\u0026thinsp;=\u0026thinsp;0.063). STR was more frequent in zone II tumors treated with FT\u0026thinsp;+\u0026thinsp;OZ (41%) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eOutcomes, Reconstruction, and Complications by Surgical Approach and Irish Zone\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"10\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eZone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eApproach\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eGTR (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e \u003cp\u003eReconstruction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003eDuraplasty\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e \u003cp\u003eComplications\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eComposite soft-tissue\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSplit calvarial\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAllo-skull implants\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eDura-allograft\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eDura-autograft\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eCSF leak\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eWound infection\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"5\" rowspan=\"6\"\u003e \u003cp\u003e\u003cb\u003eI \u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(n\u0026thinsp;=\u0026thinsp;47)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrontoTemporal Craniotomy\u0026nbsp;\u0026plusmn;\u0026nbsp;OZ Osteotomy (n\u0026thinsp;=\u0026thinsp;40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e70%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (7.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1(2.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e25 (63)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e24 (60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e6(15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e2 (5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e3 (7.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTransbasal (n\u0026thinsp;=\u0026thinsp;3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e67%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1 (33.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1 (33.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1 (2.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEndoscopic Endonasal (n\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCombined OZ plus EETPA (n\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCombined transbasal plus EEA (n\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCombined FT plus EEA (n\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003eII \u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(n\u0026thinsp;=\u0026thinsp;37)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrontoTemporal Craniotomy\u0026nbsp;\u0026plusmn;\u0026nbsp;OZ Osteotomy (n\u0026thinsp;=\u0026thinsp;27)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e59%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1(3.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e14 (52)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e21 (77.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e3 (11.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1 (3.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSubtemporal\u0026ndash;Infratemporal (n\u0026thinsp;=\u0026thinsp;6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e83%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (16.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1 (16.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2 (33.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e2 (33.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExtended MiddleFossa (n\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCombined FT\u0026thinsp;+\u0026thinsp;OZ plus EEA or EETPA (n\u0026thinsp;=\u0026thinsp;3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1 (33.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2 (66.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1 (33.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"6\" rowspan=\"7\"\u003e \u003cp\u003e\u003cb\u003eIII\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(n\u0026thinsp;=\u0026thinsp;17)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExtended MiddleFossa (n\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSubtemporal\u0026ndash;Infratemporal (n\u0026thinsp;=\u0026thinsp;2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1 (50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRetrolabyrinthine (n\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRetrosigmoid (n\u0026thinsp;=\u0026thinsp;3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1 (33.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1 (33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFar Lateral (n\u0026thinsp;=\u0026thinsp;7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e71%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (14.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1 (14.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e5 (71.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1 (14.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e2 (29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCombined Far lateral plus OZ (n\u0026thinsp;=\u0026thinsp;2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1 (50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCombined Retrosigmoid plus OZ (n\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"10\"\u003e\u003cem\u003eFootnote\u003c/em\u003e: n\u0026thinsp;=\u0026thinsp;number of cases per approach; percentages in parentheses. GTR\u0026thinsp;=\u0026thinsp;gross total resection; CSF\u0026thinsp;=\u0026thinsp;cerebrospinal fluid; OZ\u0026thinsp;=\u0026thinsp;orbitozygomatic osteotomy. Composite soft-tissue flaps include pericranial and temporalis flaps. Duraplasty \u0026ldquo;allograft\u0026rdquo; comprises DuraGen\u0026reg; and AlloDerm\u0026reg;; \u0026ldquo;autograft\u0026rdquo; comprises fascia lata, abdominal-fat grafts, and free flaps. Wound-infection rates reflect any postoperative surgical-site infection.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eWHO grade 2 tumors were significantly associated with STR compared to grade 1 (aOR 2.87, 95% CI 1.03\u0026ndash;7.99; p\u0026thinsp;=\u0026thinsp;0.043), while grade 3 histology showed no correlation with resection extent (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.76). Prior radiation (aOR 6.77; p\u0026thinsp;=\u0026thinsp;0.093) and tumors in zones II or III trended toward STR but were not statistically significant \u003cb\u003e(\u003c/b\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePredictive Factors for Subtotal Resection\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePredictor\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eaOR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWHO grade2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.13\u0026ndash;8.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.029\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWHO grade3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.05\u0026ndash;10.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.763\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCombined approaches\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.16\u0026ndash;1.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.163\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrevious radiation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.05\u0026ndash;59.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.043\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIrish Zone 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.66\u0026ndash;4.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.256\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIrish Zone 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.69\u0026ndash;7.83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.172\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKPS (\u0026gt;\u0026thinsp;70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8.73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.91\u0026ndash;33.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.011\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMaximum diameter (35mm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.47\u0026ndash;11.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.044\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTumor maximum diameter was dichotomized at 35 mm, based on optimal threshold determined by ROC analysis. KPS was dichotomized at \u0026gt;\u0026thinsp;70.\u003c/p\u003e \u003cp\u003eaOR: adjusted Odds Ratio; CI: Confidence interval.\u003c/p\u003e \u003cp\u003eMost postoperative complications were non-life-threatening (Grade I), including five Grade Ia events (metabolic disturbances) and twelve Grade Ib events (non-CNS infections, adrenal insufficiency, and deep vein thrombosis). CSF leaks (Grade II) occurred in 8% of patients: three in zone I, two in zone II, and three in zone III. In zone I, one leak followed a transbasal approach without reconstruction, and two followed FT\u0026thinsp;+\u0026thinsp;OZ approaches reconstructed with pedicled temporalis flaps, dural allografts, and PEEK cranioplasties. In zone II, leaks occurred after a transpetrosal approach reconstructed with titanium mesh and fat graft, and an FT\u0026thinsp;+\u0026thinsp;OZ approach reconstructed with a dural allograft and PEEK. In zone III, two leaks followed far-lateral approaches, and one occurred after a retrosigmoid approach, all reconstructed with dural allografts, fat grafts, and either fascia lata or titanium mesh \u003cb\u003e(\u003c/b\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u003cb\u003e).\u003c/b\u003e\u003c/p\u003e \u003cp\u003eAll CSF leaks were initially managed with lumbar drainage. One Zone III patient developed fungal meningitis, epidural abscess, and systemic infection (Grade III complication), requiring surgical repair with an anterolateral thigh (ALT) free flap. Another leak, associated with a Zone II tumor, was secondary to postoperative hydrocephalus and required treatment with a ventriculoperitoneal shunt.\u003c/p\u003e \u003cp\u003ePost-operative adjuvant radiotherapy was administered to 18 patients, predominantly with volumetric modulated arc therapy (VMAT), with a median total dose of 57 Gy.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003ePredictors of Tumor Control Rates and Overall Survival\u003c/h2\u003e \u003cp\u003eTumor recurrence occurred in 41% of patients, with a median time to recurrence of 33 months (IQR 48) \u003cb\u003e(\u003c/b\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e. WHO Grade III tumors had the highest recurrence risk (HR 27.28; p\u0026thinsp;=\u0026thinsp;0.003). STR significantly decreased PFS (HR 2.73; p\u0026thinsp;=\u0026thinsp;0.014), as did cranial nerve dysfunction (HR 2.49; p\u0026thinsp;=\u0026thinsp;0.025) and brain invasion (HR 2.99; p\u0026thinsp;=\u0026thinsp;0.036). Omission of radiotherapy was associated with worse PFS in multivariate analysis (HR 3.57; p\u0026thinsp;=\u0026thinsp;0.039) \u003cb\u003e(\u003c/b\u003eTable\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e\u003cb\u003e).\u003c/b\u003e\u003c/p\u003e \u003cp\u003eWHO grade II and III tumors were associated with higher mortality (HR 10.52; p\u0026thinsp;=\u0026thinsp;0.046 and HR 90.35; p\u0026thinsp;=\u0026thinsp;0.002, respectively). STR and Simpson grade 3 resections significantly worsened OS (HR 5.72; p\u0026thinsp;=\u0026thinsp;0.012 and HR 95.9; p\u0026thinsp;=\u0026thinsp;0.003, respectively). Cavernous sinus involvement (HR 4.36, p\u0026thinsp;=\u0026thinsp;0.017) and brain invasion (HR 5.47, p\u0026thinsp;=\u0026thinsp;0.031) also correlated with worse OS. While adjuvant radiotherapy was associated with decreased OS in univariate analysis (HR 3.22; p\u0026thinsp;=\u0026thinsp;0.035), multivariate analysis revealed a protective effect when adjusted for confounders (HR 0.15; p\u0026thinsp;=\u0026thinsp;0.029) \u003cb\u003e(\u003c/b\u003eTable\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMultivariable and Univariable Cox Regression for Recurrence-Free and Overall Survival\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eLevel\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eRecurrence-Free Survival\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eOverall Survival\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHR (Univariate)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHR (Multivariate)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHR (Univariate)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHR (Multivariate)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;50 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;50 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.49 (0.78\u0026ndash;2.84, p\u0026thinsp;=\u0026thinsp;0.223)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.05 (0.45\u0026ndash;2.45, p\u0026thinsp;=\u0026thinsp;0.914)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.45 (0.17\u0026ndash;1.22, p\u0026thinsp;=\u0026thinsp;0.118)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.27 (0.06\u0026ndash;1.13, p\u0026thinsp;=\u0026thinsp;0.074)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSex\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e2.64 (1.41\u0026ndash;4.97, p\u0026thinsp;=\u0026thinsp;0.003)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.96 (0.97\u0026ndash;3.96, p\u0026thinsp;=\u0026thinsp;0.059)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.57 (0.93\u0026ndash;7.13, p\u0026thinsp;=\u0026thinsp;0.069)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e3.72 (1.06\u0026ndash;13.07, p\u0026thinsp;=\u0026thinsp;0.040)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCranial-nerve alteration\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e3.04 (1.52\u0026ndash;6.10, p\u0026thinsp;=\u0026thinsp;0.002)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e2.49 (1.12\u0026ndash;5.53, p\u0026thinsp;=\u0026thinsp;0.025)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.03 (0.40\u0026ndash;2.69, p\u0026thinsp;=\u0026thinsp;0.945)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.98 (0.50\u0026ndash;7.76, p\u0026thinsp;=\u0026thinsp;0.328)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSeizures\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.88 (0.31\u0026ndash;2.47, p\u0026thinsp;=\u0026thinsp;0.802)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.11 (0.02\u0026ndash;0.54, p\u0026thinsp;=\u0026thinsp;0.006)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e3.23 (1.16\u0026ndash;9.01, p\u0026thinsp;=\u0026thinsp;0.025)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e4.36 (1.29\u0026ndash;14.71, p\u0026thinsp;=\u0026thinsp;0.017)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEnhancement\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHomogeneous\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHeterogeneous\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e2.03 (1.07\u0026ndash;3.87, p\u0026thinsp;=\u0026thinsp;0.031)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.35 (0.61\u0026ndash;3.03, p\u0026thinsp;=\u0026thinsp;0.460)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.62 (0.92\u0026ndash;7.47, p\u0026thinsp;=\u0026thinsp;0.072)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e10.52 (1.01-106.38, p\u0026thinsp;=\u0026thinsp;0.046)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCavernous-sinus involvement\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e13.57 (2.68\u0026ndash;68.72, p\u0026thinsp;=\u0026thinsp;0.002)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e90.35 (4.98-1640.81, p\u0026thinsp;=\u0026thinsp;0.002)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.56 (0.80\u0026ndash;3.02, p\u0026thinsp;=\u0026thinsp;0,190)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.76 (0.32\u0026ndash;1.82, p\u0026thinsp;=\u0026thinsp;0.542)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWHO grade\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGrade 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGrade 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.72 (0.88\u0026ndash;3.37, p\u0026thinsp;=\u0026thinsp;0.115)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.21 (0.70\u0026ndash;6.91, p\u0026thinsp;=\u0026thinsp;0.174)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.92 (0.69\u0026ndash;5.30, p\u0026thinsp;=\u0026thinsp;0.210)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.65 (0.20-13.92, p\u0026thinsp;=\u0026thinsp;0.645)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGrade 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e7.61 (1.65\u0026ndash;35.04, p\u0026thinsp;=\u0026thinsp;0.009)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e27.28 (3.20-232.77, p\u0026thinsp;=\u0026thinsp;0.003)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.69 (0.96\u0026ndash;7.52, p\u0026thinsp;=\u0026thinsp;0.059)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e5.47 (1.17\u0026ndash;25.59, p\u0026thinsp;=\u0026thinsp;0.031)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eKi-67 index\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e1.96 (1.04\u0026ndash;3.71, p\u0026thinsp;=\u0026thinsp;0.037)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.84 (0.70\u0026ndash;4.82, p\u0026thinsp;=\u0026thinsp;0.213)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.66 (0.62\u0026ndash;4.41, p\u0026thinsp;=\u0026thinsp;0.312)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e5.72 (1.47\u0026ndash;22.26, p\u0026thinsp;=\u0026thinsp;0.012)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBrain invasion\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e2.68 (1.21\u0026ndash;5.96, p\u0026thinsp;=\u0026thinsp;0.015)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e2.99 (1.07\u0026ndash;8.31, p\u0026thinsp;=\u0026thinsp;0.036)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e12.02 (1.11-130.39, p\u0026thinsp;=\u0026thinsp;0.041)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e42.31 (1.75-1023.95, p\u0026thinsp;=\u0026thinsp;0.021)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEOR\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e10.76 (1.06-108.75, p\u0026thinsp;=\u0026thinsp;0.044)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e95.90 (4.51-2039.06, p\u0026thinsp;=\u0026thinsp;0.003)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.63 (0.27\u0026ndash;1.45, p\u0026thinsp;=\u0026thinsp;0.274)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e3.57 (1.07\u0026ndash;11.94, p\u0026thinsp;=\u0026thinsp;0.039)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.82 (0.10-33.38, p\u0026thinsp;=\u0026thinsp;0.688)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e19.52 (0.55-689.24, p\u0026thinsp;=\u0026thinsp;0.102)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSimpson grade\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGross Total\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSubtotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.78 (0.95\u0026ndash;3.32, p\u0026thinsp;=\u0026thinsp;0.070)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e2.73 (1.23\u0026ndash;6.06, p\u0026thinsp;=\u0026thinsp;0.014)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e3.22 (1.09\u0026ndash;9.50, p\u0026thinsp;=\u0026thinsp;0.035)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.15 (0.03\u0026ndash;0.82, p\u0026thinsp;=\u0026thinsp;0.029)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSimpson 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSimpson 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e5.64 (1.86\u0026ndash;17.15, p\u0026thinsp;=\u0026thinsp;0.002)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e3.90 (1.10-13.89, p\u0026thinsp;=\u0026thinsp;0.035)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.74 (0.28\u0026ndash;1.96, p\u0026thinsp;=\u0026thinsp;0.540)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.09 (0.02\u0026ndash;0.54, p\u0026thinsp;=\u0026thinsp;0.008)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAdjuvant RT\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSimpson 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e4.46 (1.49\u0026ndash;13.29, p\u0026thinsp;=\u0026thinsp;0.007)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e5.81 (1.68\u0026ndash;20.04, p\u0026thinsp;=\u0026thinsp;0.005)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSimpson 4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e13.93 (3.34\u0026ndash;58.19, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e12.36 (2.04\u0026ndash;74.96, p\u0026thinsp;=\u0026thinsp;0.006)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.45 (0.17\u0026ndash;1.22, p\u0026thinsp;=\u0026thinsp;0.118)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.27 (0.06\u0026ndash;1.13, p\u0026thinsp;=\u0026thinsp;0.074)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRecurrence\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ndash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026ndash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ndash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026ndash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.57 (0.93\u0026ndash;7.13, p\u0026thinsp;=\u0026thinsp;0.069)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e3.72 (1.06\u0026ndash;13.07, p\u0026thinsp;=\u0026thinsp;0.040)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003cem\u003eFootnote\u003c/em\u003e: HR\u0026thinsp;=\u0026thinsp;hazard ratio; CI\u0026thinsp;=\u0026thinsp;confidence interval; EOR\u0026thinsp;=\u0026thinsp;extent of resection (GTR\u0026thinsp;=\u0026thinsp;gross total resection; STR\u0026thinsp;=\u0026thinsp;subtotal resection); RT\u0026thinsp;=\u0026thinsp;adjuvant radiotherapy; WHO\u0026thinsp;=\u0026thinsp;World Health Organization; Simpson grade refers to surgical resection scale (1\u0026ndash;4). Models adjusted for all listed covariates; likelihood-ratio p\u0026thinsp;\u0026lt;\u0026thinsp;0.001 for RFS and p\u0026thinsp;=\u0026thinsp;0.004 for OS.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eSBM-EE represents a unique subset, with recurrence rates of up to 35% and 10% at 5 years, even after GTR.[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] To our knowledge, this is the first study exploring differences in surgical approaches, tumor location, extension patterns, extent of resection (EOR), recurrence, reconstruction techniques, and associated complication rates.\u003c/p\u003e \u003cp\u003eFollowing the three sequential stages of SBM surgery\u0026sup1;\u0026sup3;\u0026mdash;exposure, subarachnoid dissection, and reconstruction\u0026mdash;we selected the most appropriate approaches to optimize EOR and enable comprehensive SB reconstruction. Within this framework, FT\u0026thinsp;\u0026plusmn;\u0026thinsp;OZ, transbasal, endonasal endoscopic, and combined approaches have demonstrated favorable EOR rates, cosmetic outcomes, and low morbidity for craniofacial SBM (zone I) [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. When extracranial invasion occurs, tumors\u0026mdash;primarily olfactory groove, planum sphenoidale, cribriform plate, and clival meningiomas\u0026mdash;often extend into the paranasal sinuses, nasal cavity, or orbit [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Consequently, most zone I lesions in our cohort were treated via FT\u0026thinsp;\u0026plusmn;\u0026thinsp;OZ, achieving a GTR in 69%, compared to 100% with EEA and 50% with the transbasal approach. These results align with previous series reporting GTR rates around 60% for zone I SBM-EE [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Although EEA is often favored for achieving higher EOR in zone I SBM-EE, its ability to address tumors with significant lateral or anterior extension\u0026mdash;and to preserve olfactory function\u0026mdash;is limited. In such cases, the transbasal approach remains preferable due to better olfactory preservation, despite generally lower GTR rates than EEA [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSphenoorbital meningiomas (SOMs) represent a distinct SBM-EE subtype, classified as zone I or II based on dominant tumor volume [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. While transorbital neuroendoscopic (TONES) approaches, combined with lateral orbitotomy, can achieve GTR in SOM, their effectiveness decreases when the pathology extends into the middle third of the sphenoid wing, the temporal floor, or the infratemporal fossa [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. In such cases, FT\u0026thinsp;+\u0026thinsp;OZ combined with subtemporal-infratemporal approaches provides more direct access, facilitating complete tumor resection and comprehensive SB reconstruction. Kong et al. [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] reported GTR rates of 51% in a series where 68% of tumors exhibited extracranial extension treated through a TONES approach. In contrast, FT combined with subtemporal approaches has achieved a GTR of 34%, primarily due to residual tumor at the orbital apex [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. In our cohort, lesions located in zone I and treated with FT\u0026thinsp;\u0026plusmn;\u0026thinsp;OZ achieved a GTR rate of 70%, and 59% in zone II lesions, whereas when a subtemporal-infratemporal approach was incorporated in the latter, the GTR rate increased to 83%.\u003c/p\u003e \u003cp\u003eAnterolateral (zone II) SBM, arising from the greater wing of the sphenoid, sphenoidal ridge, and cavernous sinus, poses unique challenges due to its tendency to extend transcranially into the infratemporal and pterygopalatine fossae [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. FT\u0026thinsp;+\u0026thinsp;OZ and subtemporal-infratemporal approaches remain the approaches of choice for these anterolateral tumors, along with or without extended middle fossa approach (i.e., transpetrosal) [\u003cspan additionalcitationids=\"CR20\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Furthermore, they allow access to the maxillary sinus by drilling the anterior limit of the pterygopalatine fossa; to the parapharyngeal space after laterally retracting the medial pterygoid muscle; and to the sphenoid sinus by drilling the base of the pterygoid process to perform a lateral sphenoidectomy [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Nakao et al [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], reported 90% GTR rates in similar tumors using these approaches. Similarly, Pieper and Al-Mefty [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], reported a GTR rate of 78% of zone II SBM operated through FT\u0026thinsp;+\u0026thinsp;OZ approach. In our cohort, GTR was achieved in 59% of zone II cases treated with FT\u0026thinsp;\u0026plusmn;\u0026thinsp;OZ and 83% of those managed with subtemporal-infratemporal approaches. Although the subtemporal-infratemporal approach seemed to provide an additional access to achieve complete resection, we found that cavernous sinus involvement, observed in 38.6% of cases, was associated with reduced likelihood of GTR. This underscores that although the appropriate approach selection remains a cornerstone to achieve GTR, STRs are pursued not due to access limitations but for patient safety in the context of a benign entity.\u003c/p\u003e \u003cp\u003ePosterolateral (zone III) SBM-EE involving the petrous bone, ear canal, the parapharyngeal space, and upper cervical soft tissue was approached via subtemporal-infratemporal, extended middle fossa, presigmoid (e.g., retrolabyrinthine), far-lateral, and retrosigmoid routes [\u003cspan additionalcitationids=\"CR25\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Our cohort demonstrated GTR rates of 71% after far lateral approaches and 100% with retrosigmoid approaches. These findings are consistent with previous reports suggesting that posterolateral foramen magnum meningiomas may offer higher GTR rates than their anterolateral counterparts, likely due to more straightforward surgical access [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eRegarding the third stage of SBM surgery, skull base reconstruction techniques ranged from simple duroplasties to comprehensive reconstructions involving the dura mater, bone (due to resection aiming to achieve a lower Simpson grade), and soft tissue. Dural reconstruction is typically performed using autologous fascial, muscle, or fat grafts and is generally more straightforward in anterior SBM-EE (Zone I) cases approached via a transbasal route, compared to reconstructions in zones II and III [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn zone I SBM-EE, a defect of 1.5 cm has been described as the threshold between the defects that can be reconstructed with autologous fascia, muscle, and fat, and those requiring combined techniques, including osseous reconstruction with autogenous bone, titanium mesh, or PEEK cranioplasties [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Autologous grafts of fat and fascia are the most commonly described to address SB defects, with the transposition of a pedicled temporalis muscle flap recommended when a watertight closure is not possible [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. In our series, comprehensive SB reconstruction was performed in cases where primary watertight closure was not feasible, a highly deformative defect was present, or when significant dead space remained. However, we found a significant difference in CSF leak rates by tumor location, with zone III SBM-EE demonstrating the highest rate (27%) compared to zone I (6.4%) and zone II (2.7%).\u003c/p\u003e \u003cp\u003eWound infections occurred in 2.9% of patients (3 of 101), all of whom had undergone an FT\u0026thinsp;+\u0026thinsp;OZ approach, and one patient required debridement (0.9%). This contrasts with the prior series of SBM-EE, where surgical debridement was 10% [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. These findings highlight the importance of meticulous skull base reconstruction and multilayer closure techniques in minimizing postoperative complications, particularly in cases requiring complex craniofacial resections and adjuvant therapies.\u003c/p\u003e \u003cp\u003eIncomplete resection has been associated with skull base location, bone/brain invasion, and higher WHO grade [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. In our cohort, STR was significantly associated with WHO grade 2 histology (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.029), prior radiation therapy (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.043), and tumors larger than 35 mm (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.044), although tumor zone did not predict STR. Similarly, WHO grade 3, brain invasion, and lack of adjuvant radiation therapy were associated with higher recurrence rates. Notably, increasing Simpson grade correlated with progressively greater recurrence risk, with hazard ratios of 3.9, 5.81, and 12.36 for Simpson grades II, III, and IV, respectively. Our results highlight the need for aggressive but anatomically mindful resection strategies and robust skull base reconstruction to optimize outcomes in SBM-EE.\u003c/p\u003e\n\u003ch3\u003eLimitations\u003c/h3\u003e\n\u003cp\u003eThis study is limited by its retrospective design and single institution setting, which may introduce selection bias and limit generalizability. The long study period may also reflect changes in surgical techniques and imaging modalities over time. Additionally, although the Irish classification was used to standardize tumor location, some overlap between zones may persist in multicompartmental tumors.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eSBM-EEs present unique surgical challenges, with EOR, WHO grade, cavernous sinus invasion, and brain invasion identified as key predictors of recurrence and survival. Tailored surgical approaches\u0026mdash;such as FT\u0026thinsp;\u0026plusmn;\u0026thinsp;OZ and subtemporal-infratemporal extensions\u0026mdash;optimize access, but achieving GTR remains difficult in multicompartmental tumors. Comprehensive skull base reconstruction is essential, particularly to minimize postoperative CSF leak rates, which were highest in Zone III tumors. Despite the surgical complexity, wound complication rates remained low. Individualized planning based on tumor location and extension is critical to balance oncological control with functional outcomes. Future refinements incorporating vascular supply patterns may further improve surgical strategy selection and patient outcomes.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cem\u003eFunding:\u0026nbsp;\u003c/em\u003eThe authors declare that no funds, grants, or other support were received during the preparation of this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCompeting Interests:\u0026nbsp;\u003c/em\u003eThe authors have no relevant financial or non-financial interests to disclose.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAuthor Contributions:\u003c/em\u003e All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Juan Pablo Zuluaga-Garc\u0026iacute;a, Esteban Ramirez-Ferrer and Sophie F. Peteers. The first draft of the manuscript was written by Juan Pablo Zuluaga-Garc\u0026iacute;a, Esteban Ramirez-Ferrer, Shaan Raza, Franco DeMonte and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eData Availability:\u0026nbsp;\u003c/em\u003eThe datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eEthics approval:\u0026nbsp;\u003c/em\u003eThis is an observational study. Institutional Review Board (IRB) protocol was approved, including Research Ethics Committee of University of Texas MD Anderson Cancer Center, and has confirmed that no ethical approval is required.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eInformed consent:\u003c/em\u003e Informed consent was waived for this study after IRB approval.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eConsent to publish:\u0026nbsp;\u003c/em\u003eThe authors affirm that human research participants provided informed consent for publication of the images in Figure(1) 1a, 1b and 1c.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eMcGovern SL, Aldape KD, Munsell MF, et al (2010) A comparison of World Health Organization tumor grades at recurrence in patients with non\u0026ndash;skull base and skull base meningiomas: Clinical article. J Neurosurg 112:925\u0026ndash;933. https://doi.org/10.3171/2009.9.JNS09617\u003c/li\u003e\n\u003cli\u003eWestphal M, Saladino A, Tatagiba M (2023) Skull Base Meningiomas. In: Zadeh G, Goldbrunner R, Krischek B, Nassiri F (eds) Biological and Clinical Landscape of Meningiomas. Springer International Publishing, Cham, pp 47\u0026ndash;68\u003c/li\u003e\n\u003cli\u003eMansouri A, Klironomos G, Taslimi S, et al (2016) Surgically resected skull base meningiomas demonstrate a divergent postoperative recurrence pattern compared with non\u0026ndash;skull base meningiomas. J Neurosurg 125:431\u0026ndash;440. https://doi.org/10.3171/2015.7.JNS15546\u003c/li\u003e\n\u003cli\u003eNakao N, Ohkawa T, Miki J, et al (2010) Surgical treatment and outcome of skull base meningiomas with extracranial extensions. Clin Neurol Neurosurg 112:40\u0026ndash;46. https://doi.org/10.1016/j.clineuro.2009.10.003\u003c/li\u003e\n\u003cli\u003eLiu H, Qian H, Li X, et al (2020) Clinial Features, Individualized Treatment and Long-Term Surgical Outcomes of Skull Base Meningiomas With Extracranial Extensions. Front Oncol 10:1054. https://doi.org/10.3389/fonc.2020.01054\u003c/li\u003e\n\u003cli\u003eGabriel PJ, Kohli G, Hsueh WD, et al (2020) Efficacy of simultaneous pericranial and nasoseptal \u0026ldquo;double flap\u0026rdquo; reconstruction of anterior skull base defects after combined transbasal and endoscopic endonasal approaches. Acta Neurochir (Wien) 162:641\u0026ndash;647. https://doi.org/10.1007/s00701-019-04155-1\u003c/li\u003e\n\u003cli\u003eFraser S, Gardner PA, Koutourousiou M, et al (2018) Risk factors associated with postoperative cerebrospinal fluid leak after endoscopic endonasal skull base surgery. J Neurosurg 128:1066\u0026ndash;1071. https://doi.org/10.3171/2016.12.JNS1694\u003c/li\u003e\n\u003cli\u003eHe W, Liu Z, Jie D, et al (2022) Management of Skull-Base Meningiomas With Extracranial Extensions: Clinical Features, Radiological Findings, Surgical Strategies, and Long-Term Outcomes. Front Neurol 13:855973. https://doi.org/10.3389/fneur.2022.855973\u003c/li\u003e\n\u003cli\u003eIrish JC, Gullane PJ, Gentili F, et al (1994) Tumors of the skull base: Outcome and survival analysis of 77 cases. Head Neck 16:3\u0026ndash;10. https://doi.org/10.1002/hed.2880160103\u003c/li\u003e\n\u003cli\u003eIba\u0026ntilde;ez FAL, Hem S, Ajler P, et al (2011) A New Classification of Complications in Neurosurgery. World Neurosurg 75:709\u0026ndash;715. https://doi.org/10.1016/j.wneu.2010.11.010\u003c/li\u003e\n\u003cli\u003eHeinze G, Schemper M (2002) A solution to the problem of separation in logistic regression. Stat Med 21:2409\u0026ndash;2419. https://doi.org/10.1002/sim.1047\u003c/li\u003e\n\u003cli\u003eRStudio Team RStudio: Integrated Development for R\u003c/li\u003e\n\u003cli\u003eLeonetti JP, Reichman OH, Smith PG, et al (1990) Meningiomas of the lateral skull base: Neurotologic manifestations and patterns of recurrence. Otolaryngol Neck Surg 103:972\u0026ndash;980. https://doi.org/10.1177/019459989010300615\u003c/li\u003e\n\u003cli\u003ePeto I, Monsour M, Piper K, et al (2023) Nasofrontal meningiomas: retrospective series and review of literature. Neurosurg Rev 46:158. https://doi.org/10.1007/s10143-023-02053-w\u003c/li\u003e\n\u003cli\u003eOttenhausen M, Rumalla K, Alalade AF, et al (2018) Decision-making algorithm for minimally invasive approaches to anterior skull base meningiomas. Neurosurg Focus 44:E7. https://doi.org/10.3171/2018.1.FOCUS17734\u003c/li\u003e\n\u003cli\u003eLiu JK, Silva NA, Sevak IA, Eloy JA (2018) Transbasal versus endoscopic endonasal versus combined approaches for olfactory groove meningiomas: importance of approach selection. Neurosurg Focus 44:E8. https://doi.org/10.3171/2018.1.FOCUS17722\u003c/li\u003e\n\u003cli\u003eKiyofuji S, Casabella AM, Graffeo CS, et al (2020) Sphenoorbital meningioma: a unique skull base tumor. Surgical technique and results. J Neurosurg 133:1044\u0026ndash;1051. https://doi.org/10.3171/2019.6.JNS191158\u003c/li\u003e\n\u003cli\u003eKong D-S, Kim YH, Hong C-K (2021) Optimal indications and limitations of endoscopic transorbital superior eyelid surgery for spheno-orbital meningiomas. J Neurosurg 134:1472\u0026ndash;1479. https://doi.org/10.3171/2020.3.JNS20297\u003c/li\u003e\n\u003cli\u003eBernardo A, Evins AI (2023) Anterolateral Routes to the Skull Base\u0026mdash;The Frontotemporal Approaches and Exposure of the Sellar and Parasellar Regions. World Neurosurg 172:131\u0026ndash;145. https://doi.org/10.1016/j.wneu.2022.11.055\u003c/li\u003e\n\u003cli\u003eSoleman J, Leiggener C, Schlaeppi A-J, et al (2016) The Extended Subfrontal and Fronto-Orbito-Zygomatic Approach in Skull Base Meningioma Surgery: Clinical, Radiologic, and Cosmetic Outcome. J Craniofac Surg 27:433\u0026ndash;440. https://doi.org/10.1097/SCS.0000000000002368\u003c/li\u003e\n\u003cli\u003eBir SC, Maiti T, Konar S, Nanda A (2017) Comparison of the Surgical Outcome of Pterional and Frontotemporal-Orbitozygomatic Approaches and Determination of Predictors of Recurrence for Sphenoid Wing Meningiomas. World Neurosurg 99:308\u0026ndash;319. https://doi.org/10.1016/j.wneu.2016.10.057\u003c/li\u003e\n\u003cli\u003ePieper DR, Al-Mefty O (1999) Management of Intracranial Meningiomas Secondarily Involving the Infratemporal Fossa: Radiographic Characteristics, Pattern of Tumor Invasion, and Surgical Implications. Neurosurgery 45:231\u0026ndash;237. https://doi.org/10.1097/00006123-199908000-00005\u003c/li\u003e\n\u003cli\u003eSun DQ, Menezes AH, Howard MA, et al (2018) Surgical Management of Tumors Involving Meckel\u0026rsquo;s Cave and Cavernous Sinus: Role of an Extended Middle Fossa and Lateral Sphenoidectomy Approach. Otol Neurotol 39:82\u0026ndash;91. https://doi.org/10.1097/MAO.0000000000001602\u003c/li\u003e\n\u003cli\u003eHoz SS, Palmisciano P, Albairmani SS, et al (2023) A proposed classification system for presigmoid approaches: a scoping review. J Neurosurg 139:965\u0026ndash;971. https://doi.org/10.3171/2023.2.JNS222227\u003c/li\u003e\n\u003cli\u003eTummala RP, Coscarella E, Morcos JJ (2005) Transpetrosal approaches to the posterior fossa. Neurosurg Focus 19:1\u0026ndash;9. https://doi.org/10.3171/foc.2005.19.2.7\u003c/li\u003e\n\u003cli\u003eBernardo A, Evins AI (2023) Posterolateral Routes to the Skull Base, Craniocervical Junction, and Jugular Foramen\u0026mdash;The Far Lateral Transcondylar Approach and Combined Transpetrosal Transcervical Approaches. World Neurosurg 172:163\u0026ndash;174. https://doi.org/10.1016/j.wneu.2022.11.053\u003c/li\u003e\n\u003cli\u003ePaun L, Gondar R, Borrelli P, Meling TR (2021) Foramen magnum meningiomas: a systematic review and meta-analysis. Neurosurg Rev 44:2583\u0026ndash;2596. https://doi.org/10.1007/s10143-021-01478-5\u003c/li\u003e\n\u003cli\u003eHe J, Lu J, Zhang F, et al (2021) The Treatment Strategy for Skull Base Reconstruction for Anterior Cranial Fossa Intra- and Extracranial Tumors. J Craniofac Surg 32:1673\u0026ndash;1678. https://doi.org/10.1097/SCS.0000000000007244\u003c/li\u003e\n\u003cli\u003eLem\u0026eacute;e J-M, Corniola MV, Da Broi M, et al (2019) Extent of Resection in Meningioma: Predictive Factors and Clinical Implications. Sci Rep 9:5944. https://doi.org/10.1038/s41598-019-42451-z\u003c/li\u003e\n\u003cli\u003eKim D, Niemierko A, Hwang WL, et al (2018) Histopathological prognostic factors of recurrence following definitive therapy for atypical and malignant meningiomas. J Neurosurg 128:1123\u0026ndash;1132. https://doi.org/10.3171/2016.11.JNS16913\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-neuro-oncology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"neon","sideBox":"Learn more about [Journal of Neuro-Oncology](https://www.springer.com/journal/11060)","snPcode":"11060","submissionUrl":"https://submission.nature.com/new-submission/11060/3","title":"Journal of Neuro-Oncology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Meningioma, Intracranial Neoplasm, Skull Base Surgery, Gross Total Resection, Prognostic Factors, Postoperative Complications","lastPublishedDoi":"10.21203/rs.3.rs-6590546/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6590546/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eTo assess clinical, radiographic, surgical, and pathological factors affecting outcomes in patients with skull-base meningiomas (SBMs) with extracranial extension, focusing on extent of resection (EOR), recurrence rates, postoperative complications, and skull-base (SB) reconstruction strategies.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe conducted a retrospective cohort study of 101 patients with SBMs and transcranial extension treated surgically between 1993 and 2024. Tumors were categorized by the Irish classification (Zones I\u0026ndash;III). We collected demographics, imaging, surgical details (approach and EOR), pathology (WHO grade, brain invasion, cranial-nerve involvement), and adjuvant therapy. Primary outcomes included gross total resection (GTR) rate, postoperative complications, progression-free survival (PFS), and overall survival (OS). Multivariable Cox-regression and Firth\u0026rsquo;s-logistic regression identified independent predictors.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eZone I was most common (47%), with orbital (41%) and infratemporal-fossa (18%) extension. GTR was achieved in 61.4% overall\u0026mdash;highest in Zone I (70.2%). Cerebrospinal-fluid leaks occurred in 8% (highest in Zone III, 27%), and wound infections in 2.9%, none requiring debridement. Tumor recurrence occurred in 40%; subtotal resection (STR; hazard ratio [HR] 2.73, p\u0026thinsp;=\u0026thinsp;0.014), WHO grade III (HR 27.3, p\u0026thinsp;=\u0026thinsp;0.003), cranial-nerve dysfunction, and brain invasion independently predicted reduced PFS. STR, Simpson grade\u0026thinsp;\u0026gt;\u0026thinsp;1, cavernous-sinus invasion, and brain invasion predicted worse OS. Multidisciplinary SB reconstruction using autologous grafts and prosthetic materials (PEEK, titanium mesh) was essential to minimize morbidity.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eSBMs with extracranial extension present complex surgical challenges. EOR, tumor histology, and invasion of critical structures significantly influence recurrence and survival. Tailored surgical planning by zone and comprehensive SB reconstruction are critical to optimize outcomes and reduce postoperative morbidity.\u003c/p\u003e","manuscriptTitle":"Management of Skull Base Meningiomas with Extracranial Extension: Resection, Recurrence, and Prognostic Factors","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-08 14:49:35","doi":"10.21203/rs.3.rs-6590546/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-05-17T12:32:41+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-16T01:05:32+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-12T05:50:55+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"31766228016035765064919177562988996346","date":"2025-05-07T13:20:04+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"284268411110735783046922031155901458312","date":"2025-05-06T11:23:03+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"339874270441012016470352122918934331786","date":"2025-05-05T15:15:52+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-05-05T13:14:41+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-05-05T13:08:14+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-05T13:01:51+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Neuro-Oncology","date":"2025-05-05T00:48:04+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-neuro-oncology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"neon","sideBox":"Learn more about [Journal of Neuro-Oncology](https://www.springer.com/journal/11060)","snPcode":"11060","submissionUrl":"https://submission.nature.com/new-submission/11060/3","title":"Journal of Neuro-Oncology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"9230e374-0bc7-4b9e-be1c-0f4a431d0f33","owner":[],"postedDate":"May 8th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-06-23T16:02:37+00:00","versionOfRecord":{"articleIdentity":"rs-6590546","link":"https://doi.org/10.1007/s11060-025-05111-z","journal":{"identity":"journal-of-neuro-oncology","isVorOnly":false,"title":"Journal of Neuro-Oncology"},"publishedOn":"2025-06-19 15:57:51","publishedOnDateReadable":"June 19th, 2025"},"versionCreatedAt":"2025-05-08 14:49:35","video":"","vorDoi":"10.1007/s11060-025-05111-z","vorDoiUrl":"https://doi.org/10.1007/s11060-025-05111-z","workflowStages":[]},"version":"v1","identity":"rs-6590546","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6590546","identity":"rs-6590546","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}