Simpson Grading and Risk of Recurrence in 4074 Meningioma Patients With Gross Total Resection

BACKGROUND AND OBJECTIVES: Simpson grading remains the most widely used clinical classification of extent of resection in meningioma surgery, yet its relevance in modern neurosurgical practice remains debated. The aim was to evaluate whether Simpson grading is associated with recurrence risk after gross total resection (GTR) of intracranial meningiomas within the context of tumor biology and anatomic location. METHODS: We analyzed 4074 patients undergoing GTR (Simpson grades 1-3) for primary intracranial meningioma, compiling data from 42 institutions worldwide. Cumulative incidence of recurrence was estimated using Aalen-Johansen methods. Multivariable inverse probability of censoring weighted logistic regression models were used to estimate adjusted recurrence risks at 5 and 10 years, adjusting for age, sex, World Health Organization (WHO) grade, Ki-67 proliferation index, and healthcare system setting. RESULTS: Higher Simpson grades were consistently associated with increased recurrence risk in WHO-1 and WHO-2. Among WHO-1, Simpson grade 2 had more than twice the recurrence odds compared with grade 1 at 5 years, whereas grade 3 showed even higher odds ratio of 3.47 (95% CI, 1.98-6.08). Similar patterns were observed in WHO-2 tumors. Interaction analyses suggested that differences between Simpson grades increase with higher Ki-67 proliferation indices. The prognostic significance of Simpson grade varied across anatomic locations, with clear associations observed for convexity and skull-base meningiomas, but limited relevance for parasagittal/falx meningiomas irrespective of WHO grade. CONCLUSION: Simpson grading remained strongly associated with recurrence after GTR. These findings suggest that the extent of dural and bony clearance remains clinically relevant; however, Simpson grading should be contextualized within tumor biology and anatomic constraints. Future recurrence models integrating molecular and surgical variables may refine prognostic frameworks rather than current standalone classification systems.

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Journal
Neurosurgery
Published
2026-09-21
DOI
https://doi.org/10.1227/neu.0000000000004213
Primary Topic
Meningioma and schwannoma management
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article
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article

Simpson Grading and Risk of Recurrence in 4074 Meningioma Patients With Gross Total Resection

Ricardo Prat-Acín, Soichi Oya, Tamás Csonka, Matthew Koshy et al.
Neurosurgery
Meningioma and schwannoma management
article

Simpson Grading and Risk of Recurrence in 4074 Meningioma Patients With Gross Total Resection

Ricardo Prat-Acín, Soichi Oya, Tamás Csonka, Matthew Koshy, Junkoh Yamamoto, Jacob S. Young, Tony Catalan, Ian G. Law, Tiit Illimar Mathiesen, John Ta-Hsiang Tsiang, Jong Hee Chang, María Dolores Tabernero, Chang‐Ok Suh, Satoru Miyawaki, Ilker Y. Eyüpoglu, Yasuhiro Kuroi, Young Zoon Kim, Dorothee Cäcilia Spille, Tina Nørgaard Munch, Vikram C. Prabhu, Bjarne Winther Kristensen, Luís Souhami, Luca Bertero, Matthias Simon, Konstantinos Gousias, Daniel W. Kim, Tiemo Jürgen Klisch, Dennis C. Shrieve, Benjamin Brokinkel, Philip V. Theodosopoulos, Stephen T. Magill, Helen Alice Shih, Andrea Daniela Maier, Simon Skyrman, Maria Kamenova, Michael E. Ivan, Manoel Antônio de Paiva Neto, Lasse Rehné Jensen, Sven Straumann, SVERRE HELGE TORP, Tareq Adnan Juratli, Christian Mirian, Kåre Fugleholm, Akash J. Patel, Austin Lui, Torstein Ragnar Meling, Stéphane Goutagny, Anders Broechner, Joo Ho Lee, Karthikeyan Perumal, Donald M. Cannon, Olivia Claire Barrett, Adam Gorm Hoffmann, Ricardo Komotar, Jennifer Moliterno, Paul Blanche, Aria Jamshidi, Pedro Góes, Francesco Maiuri, Ramin A. Morshed, Jehuda Soleman, Nobuhito Saito, Toshiki Endo, Erdem Güresir, Michael W. McDermott, Marie-Christine Guiot, Johannes Wach, Evan Luther, Martin Proescholdt, Walter Stummer, Valeria Barresi, Mustafa K. Baskaya, Tejpal Gupta, Randy Jensen, Jun Won Kim
article en

Abstract

BACKGROUND AND OBJECTIVES: Simpson grading remains the most widely used clinical classification of extent of resection in meningioma surgery, yet its relevance in modern neurosurgical practice remains debated. The aim was to evaluate whether Simpson grading is associated with recurrence risk after gross total resection (GTR) of intracranial meningiomas within the context of tumor biology and anatomic location. METHODS: We analyzed 4074 patients undergoing GTR (Simpson grades 1-3) for primary intracranial meningioma, compiling data from 42 institutions worldwide. Cumulative incidence of recurrence was estimated using Aalen-Johansen methods. Multivariable inverse probability of censoring weighted logistic regression models were used to estimate adjusted recurrence risks at 5 and 10 years, adjusting for age, sex, World Health Organization (WHO) grade, Ki-67 proliferation index, and healthcare system setting. RESULTS: Higher Simpson grades were consistently associated with increased recurrence risk in WHO-1 and WHO-2. Among WHO-1, Simpson grade 2 had more than twice the recurrence odds compared with grade 1 at 5 years, whereas grade 3 showed even higher odds ratio of 3.47 (95% CI, 1.98-6.08). Similar patterns were observed in WHO-2 tumors. Interaction analyses suggested that differences between Simpson grades increase with higher Ki-67 proliferation indices. The prognostic significance of Simpson grade varied across anatomic locations, with clear associations observed for convexity and skull-base meningiomas, but limited relevance for parasagittal/falx meningiomas irrespective of WHO grade. CONCLUSION: Simpson grading remained strongly associated with recurrence after GTR. These findings suggest that the extent of dural and bony clearance remains clinically relevant; however, Simpson grading should be contextualized within tumor biology and anatomic constraints. Future recurrence models integrating molecular and surgical variables may refine prognostic frameworks rather than current standalone classification systems.

Neurosurgery
Statens Serum Institut (DK), Northwestern University (US), University of Verona (IT), University of Copenhagen (DK), Loyola University Medical Center (US), University of Debrecen (HU), University of Wisconsin–Madison (US), Seoul National University (KR), University of California, San Francisco (US), Baylor College of Medicine (US), University of Occupational and Environmental Health Japan (JP), Yonsei University (KR), Hochschule Bielefeld (DE), Université Paris Cité (FR), Norwegian University of Science and Technology (NO), University of Münster (DE), Samsung (South Korea) (KR), Hôpital Beaujon (FR), Allegheny General Hospital (US), Spencer Foundation (US), Huntsman Cancer Institute (US), McGill University Health Centre (CA), University Hospital of Basel (CH), Copenhagen University Hospital (DK), Rigshospitalet (DK), Seoul National University Hospital (KR), Karolinska Institutet (SE), Hospital Universitari i Politècnic La Fe (ES), University Hospital Regensburg (DE), University of Illinois Chicago (US), Massachusetts General Hospital (US), Assistance Publique – Hôpitaux de Paris (FR), Center for Neuro-Oncology (US), University Hospital Münster (DE), St Olav's University Hospital (NO), Evangelisches Krankenhaus Bielefeld (DE), University of Tokyo Hospital (JP), Department of Medical Sciences (RU), Neurological Research Institute (US), Federico II University Hospital (IT), Leitat Technological Center (ES), Mobile Infirmary (US), University of Illinois Hospital & Health Sciences System (US), University Hospital Leipzig (DE), Athens Medical Center (GR), Clemenshospital Münster (DE), Instituto de Investigación Biomédica de Salamanca (ES), Tokyo Women's Medical University Adachi Medical Center (JP), Tokyo Women's Medical University (JP), Gangnam Severance Hospital (KR), Wisconsin Division of Public Health (US), Hackensack Meridian Health (US), Center for Cancer Research (US), Miami Transplant Institute (US), Sylvester Comprehensive Cancer Center (US), Advanced Centre for Treatment, Research and Education in Cancer (IN), Neurological Surgery (US), University Hospital Carl Gustav Carus (DE), Fondazione IRCCS Istituto Neurologico Carlo Besta (IT), Smilow Cancer Hospital (US), University of Regensburg (DE), FH Münster (DE), University of Naples Federico II (IT), Sungkyunkwan University (KR), Tohoku Medical and Pharmaceutical University (JP), Saitama Medical University (JP), Universidade Federal de São Paulo (BR), Bethel University (US)
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Meningioma and schwannoma management
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