Letter: Integrated Clinical Genetic Analysis of Meningiomas Causing Bony Hyperostosis Shows More Severe Clinical Course and Overexpression of Secreted Pro-Osteogenic Factors

To the Editor: We read with great interest the timely and insightful article entitled “Integrated Clinical Genetic Analysis of Meningiomas Causing Bony Hyperostosis Shows More Severe Clinical Course and Overexpression of Secreted Pro-Osteogenic Factors,” recently published in Neurosurgery.1 We sincerely commend the authors for their meticulous and comprehensive retrospective analysis of 181 primary meningiomas. Their multidisciplinary work highlights the clinical severity and transcriptional signatures associated with hyperostosis, offering valuable insights with clear potential implications for surgical planning and multidisciplinary care. In this context, as a dedicated multidisciplinary meningioma program as well, we would like to share additional perspectives prompted by this thought-provoking and pertinent investigation. Primarily, the authors' findings underscore the significant reconstructive implications of hyperostotic meningiomas, as evidenced by the increased need for craniectomy and cranioplasty (27% vs 5% for craniectomy; 14% vs 2% for cranioplasty). These results bring important attention to how hyperostosis and osseous invasion influence both surgical reconstruction and postoperative outcomes. In such scenarios, radical bone resection is often necessary to achieve Simpson grade I resection and minimize recurrence, although this is accompanied by heightened intraoperative complexity—including higher estimated blood loss (342 mL vs 197 mL) and longer operative times (371 minutes vs 329 minutes). Unlike nonhyperostotic cases, where autologous bone flaps can often be reused with minimal modification, extensive invasion frequently necessitates synthetic cranioplasty materials, which may increase complication rates, with infection remaining the most frequent issue in nonautologous implants (10%-30%).2,3 These more demanding cases may benefit from early collaboration with neuroplastic, or reconstructive surgeons to optimize volumetric restoration and functional outcomes, further reinforcing the value of a multidisciplinary collaboration.4 Additionally, the increased rates of postoperative complications—such as deep venous thrombosis (6% vs 1%) and new seizures (14% vs 3%)—underscore the need for careful perioperative planning, likely reflecting longer surgical times and inflammatory changes in invaded bone. This work also encourages reflection on the expanding role of multidisciplinary teams in managing hyperostotic meningiomas. As outlined in recent frameworks, integrating neurosurgery, neuroplastic surgery, radiology, radiation oncology, and molecular pathology can meaningfully enhance outcomes. For instance, advanced imaging modalities, such as 68Ga-DOTATATE PET/CT, can improve the delineation of intraosseous tumor extension and support more precise, individualized surgical planning.5,6 Similarly, preoperative 3-dimensional printing of customized implants and cutting guides can help achieve optimal craniofacial reconstruction, ensuring better functional and aesthetic outcomes.7 In our experience in a dedicated multidisciplinary meningioma program, composed of a neuroplastic surgeon, neurosurgeons, radiologists, oncologists, and a robust team of engineers, we successfully employ the integration of computer-aided design/computer-aided manufacturing 3-dimensional customized implants planned carefully beforehand, complemented by a tailored cutting guide to guide the craniotomy and allow for a precise “lock-and-key” implantation of the implant, even in complex anatomic areas such as the spheno-orbital and temporal fossa regions. This controlled and guided craniectomy has enabled us to perform effective and safe single-stage resections and reconstructions of hyperostotic meningiomas, yielding improved surgical, postoperative, esthetic, and functional outcomes compared with the evidence on other reported approaches, even in complex cases. In this sense, we believe that these patients should be approached and treated in a dedicated multidisciplinary meningioma program. We also believe that, just as breast oncoplastic surgery and oculoplastic surgery have evolved in past decades, neurosurgery is poised to advance to a new era by considering the concept of Oncoplastic Neurosurgery. In our Neuroplastic & Reconstructive program, we are striving to push every aspect of neuro-oncological reconstruction in this regard, and have been promoting the Oncoplastic Neurosurgery concept, approach, and program to address these challenging pathologies. In this sense, we consider that this study provides insightful evidence that the “Oncoplastic Neurosurgery” paradigm should be further developed, adopted, and disseminated to benefit patients requiring tailored and complex reconstructions after brain and/or skull neoplasms resection. In summary, these observations are intended to contribute constructively to the ongoing discourse surrounding meningioma hyperostosis and its implications in cranioplasties and soft tissue restoration with multidisciplinary teams. We reiterate our appreciation for the necessity and novelty of the work and express our hope that these comments may stimulate further research efforts aimed at refining surgical strategies and multidisciplinary protocols for these challenging cases.