What are the management options for meningioma (brain tumor)?

From the Guidelines

The management of meningiomas should prioritize a multidisciplinary approach, including observation, surgery, radiation therapy, and potentially peptide receptor radionuclide therapy (PRRT), depending on tumor size, location, and symptoms, as well as patient age, comorbidities, and preferences. When considering treatment options, it is essential to weigh the benefits and risks of each approach, taking into account the potential impact on morbidity, mortality, and quality of life. For asymptomatic, small meningiomas discovered incidentally, observation with regular MRI scans every 6-12 months is often recommended 1. Surgical resection is the primary treatment for symptomatic meningiomas or those showing growth during observation, with complete resection (Simpson Grade I or II) offering the best chance for cure, and recurrence rates of 7-20% at 10 years 1. Some key points to consider in the management of meningiomas include:

• The use of radiolabeled somatostatin receptor ligands for diagnostics and therapy (theranostics) of meningiomas, which can provide excellent lesion-to-background contrast and detection sensitivities superior to contrast-enhanced MRI alone 1
• The potential benefits of PRRT in patients with treatment-refractory meningioma, although randomized clinical trials on the efficacy of PRRT in meningiomas are missing 1
• The importance of individualizing the management approach based on tumor characteristics, patient age, comorbidities, and preferences, with the goal of controlling tumor growth while minimizing treatment-related morbidity 1
• The value of SSTR PET in differentiating recurrent disease from treatment-related changes, such as radionecrosis or scar tissue, at suspected tumor recurrence 1 In terms of specific treatment options, stereotactic radiosurgery (15-16 Gy in a single fraction) or fractionated radiotherapy (50-54 Gy in 1.8-2.0 Gy fractions) may be considered for residual tumor, recurrence, or high-risk meningiomas. Additionally, medical therapy, including somatostatin analogs (octreotide), hydroxyurea, or hormonal agents, may be used for refractory cases, although its efficacy is limited 1. Ultimately, the management of meningiomas requires a comprehensive and individualized approach, taking into account the latest evidence and guidelines, as well as the unique needs and circumstances of each patient.

From the Research

Treatment Options for Meningioma

• Surgery is the primary treatment for meningiomas, with the goal of gross-total resection, especially for parasagittal, lateral sphenoid wing, and olfactory groove meningiomas 2
• Radiation therapy is an option as a primary treatment for small meningiomas and for treatment of recurrences after surgery, with advanced technologies such as image guidance and stereotactic methods 3
• Stereotactic radiosurgery can be used as an alternative treatment to surgery, either as a first-line treatment or at recurrence, with a high local control rate and minimal toxicity 2, 4
• Fractionated external-beam radiation therapy (EBRT) can be used as an adjuvant to surgery for subtotally resected, recurrent, or higher-grade meningiomas 5
• Chemotherapy has modest activity and is reserved for selected cases, with ongoing clinical trials to evaluate its effectiveness 2, 6

Surgical Approaches

• Gross-total resection should be the goal for parasagittal, lateral sphenoid wing, and olfactory groove meningiomas 2
• Subtotal resection can be achieved via several surgical approaches for meningiomas of the sphenoid wing with osseous involvement or involvement of the cavernous sinus 2
• Subtotal resection rather than gross-total resection can preserve neurological function for meningiomas of the petroclival, parasellar, and posterior fossa regions 2

Radiation Therapy Techniques

• Photon energy derived from a linear accelerator using intensity modulated techniques is the most common form of treatment 3
• Protons and photons can be delivered using multiple beam paths converging on the target 3
• Fractionated treatment, with radiation delivered in multiple sessions, can be used for larger tumors or for patients who cannot undergo surgery 3
• Stereotactic radiosurgery, with a high dose of radiation delivered in a single session, can be used for smaller tumors or for patients with recurrent tumors 4