What are the treatment options for meningioma?

Treatment Options for Meningioma

The primary treatment for meningioma is surgical resection when feasible, followed by radiation therapy for high-grade tumors or incomplete resections, with observation being appropriate for small asymptomatic lesions. 1

Initial Treatment Decision Algorithm

Treatment decisions for meningiomas should follow a structured approach based on tumor size, symptoms, and accessibility:

Small Meningiomas (<30mm)

• Asymptomatic: Observation is preferred (follow with MRI at 6 months, then yearly) 1
• Symptomatic:
  • If accessible: Surgical resection
  • If inaccessible: Radiation therapy (external beam or stereotactic radiosurgery)

Large Meningiomas (≥30mm)

• Asymptomatic:
  • If accessible: Surgical resection
  • If inaccessible: Observation or radiation therapy
• Symptomatic:
  • If accessible: Surgical resection
  • If inaccessible: Radiation therapy

Surgical Management

Surgery remains the gold standard treatment for meningiomas when complete resection can be achieved with minimal morbidity 2. The goals of surgery include:

• Tissue diagnosis
• Relief of mass effect and neurological symptoms
• Complete tumor removal when possible
• Preservation of neurological function

Surgical techniques have advanced significantly with:

• Microscopic and endoscopic approaches
• Image-guided navigation
• Intraoperative neurophysiological monitoring
• Ultrasonic surgical aspirators and lasers for difficult tumors 3

Total tumor resection significantly improves outcomes, with studies reporting 97% success rates in achieving complete resection 3. The Simpson grading system guides the extent of resection needed, with Grade I (complete tumor removal with dural attachment) offering the best long-term outcomes.

Radiation Therapy

Radiation therapy plays a crucial role in meningioma management in several scenarios:

• Primary treatment: For tumors in critical locations where surgery carries high risk 1, 4
• Adjuvant treatment: Following incomplete resection or for WHO grade 3 tumors 1
• Recurrent disease: For tumors that recur after surgery 5

Radiation options include:

1. Stereotactic radiosurgery (SRS): Single high-dose radiation for smaller tumors
2. Fractionated external beam radiation therapy: For larger tumors or those near critical structures
3. Proton therapy: Considered in select cases to minimize radiation to surrounding tissues

SRS has proven effective as both primary treatment for small to moderate-sized meningiomas and as adjuvant therapy following subtotal resection 2, 4.

Advanced Treatment Options

For recurrent or treatment-resistant meningiomas, newer options are emerging:

• Peptide Receptor Radionuclide Therapy (PRRT): For meningiomas with somatostatin receptor expression, PRRT using [177Lu]Lutetium or [90Y]Yttrium has shown promising results in treatment-refractory cases 1
• Chemotherapy: Limited efficacy but options include hydroxyurea for recurrent disease 6
• Targeted therapies: Emerging treatments targeting molecular pathways involved in meningioma growth 6

Follow-up Recommendations

• MRI surveillance at 6 months after initial diagnosis/treatment
• Annual imaging thereafter for stable disease
• SSTR-directed PET imaging may help differentiate recurrence from treatment-related changes 1

Important Considerations

• WHO grade matters: Grade 1 (benign) meningiomas have excellent prognosis with complete resection, while Grade 2 (atypical) and Grade 3 (malignant) require more aggressive management including adjuvant radiation 1
• Location impacts approach: Skull base meningiomas often require multimodal treatment with planned subtotal resection followed by radiation 2
• Growth rate: Meningiomas typically grow slowly at approximately 4mm per year 1
• Multidisciplinary approach: Treatment planning should involve neurosurgeons, radiation oncologists, and other specialists 1

Pitfalls to Avoid

• Overtreatment of asymptomatic small meningiomas: Many can be safely observed
• Underestimating the value of complete resection: Total removal significantly reduces recurrence risk
• Delaying radiation for high-grade tumors: WHO grade 3 meningiomas should receive adjuvant radiation promptly
• Overlooking spinal evaluation: 70% of NF2 patients have spinal tumors that may require treatment 1

The median growth rate for meningiomas is approximately 4mm per year, which supports observation as a reasonable approach for small, asymptomatic lesions 1.