What are the treatment options for a patient with recurrent meningioma?

Treatment Options for Recurrent Meningioma

For patients with recurrent meningioma, the treatment algorithm should prioritize somatostatin receptor-directed peptide receptor radionuclide therapy (PRRT) for cases where surgical and conventional radiotherapy options have been exhausted. 1

Diagnostic Evaluation

Before determining treatment options, proper diagnostic evaluation is essential:

• SSTR PET imaging should be obtained to:

  • Differentiate recurrent meningioma from treatment-related changes/scar tissue
  • Assess tumor extent and potential osseous involvement
  • Evaluate for multifocal disease 1

• Brain MRI within 2 weeks prior to any treatment to establish baseline for monitoring 1

Treatment Algorithm for Recurrent Meningioma

First-Line Options:

1. Surgical Resection

   • Indicated for local recurrence where complete resection is possible
   • Complete resection is often curative for benign meningiomas 2
   • Consider placement of carmustine wafers in the surgical bed during reoperation 1

2. Radiation Therapy

   • For incompletely resected or recurrent tumors not previously irradiated 2
   • Options include:
     • Conventional external-beam radiation therapy (minimum 59.4 Gy for WHO grade 2) 3
     • Stereotactic radiosurgery (SRS) for smaller tumors
     • Reirradiation if prior radiation produced good/durable response 1

Second-Line Options (When Surgery/Conventional RT Not Feasible):

1. Somatostatin Receptor-Directed PRRT

   • Indicated when other local therapy options (surgery, radiotherapy) are no longer applicable
   • Patient eligibility criteria:
     • Positive somatostatin receptor expression on SSTR PET imaging within last 2 months
     • Karnofsky performance status above 60% or ECOG 0-2
     • No contraindications (renal, bone marrow, or hepatic dysfunction) 1
   • Uses [177Lu]Lutetium or [90Y]Yttrium as β-emitters that selectively target tumor tissue 1

2. Systemic Therapy

   • Consider for patients with favorable performance status after surgical options exhausted 1
   • Hydroxyurea has shown modest success in recurrent meningiomas 2
   • Hormonal therapy may be considered when all other treatments have failed 2

3. Alternating Electric Field Therapy

   • Category 2B option for recurring glioblastoma, may be considered for meningioma in select cases 1

Special Considerations

For WHO Grade 2 (Atypical) Meningiomas:

• Higher recurrence rates (41% at 5 years, 48% at 10 years after gross total resection) 4
• Consider adjuvant radiation even after gross total resection 4, 3
• Conventionally fractionated RT to at least 59.4 Gy is standard of care 3

For Multiple/Diffuse Recurrences:

• Surgery primarily to relieve mass effect 1
• Consider PRRT if SSTR-positive on PET imaging 1
• Palliative/best supportive care for patients with poor performance status 1

Response Assessment

• Follow with serial MRI scans (every 2-4 months for 2-3 years, then less frequently) 1
• Consider SSTR PET for response assessment after PRRT (>25% reduction in uptake may indicate positive response) 1
• Be aware that MRI may appear worse during the first 3 months after radiation due to BBB dysfunction, not necessarily indicating progression 1

Pitfalls to Avoid

1. Misinterpreting post-radiation changes as recurrence

   • MR spectroscopy, MR perfusion, or PET should be considered to rule out radiation-induced necrosis or "pseudoprogression" 1

2. Delaying treatment for recurrence

   • Early detection and treatment of recurrence is warranted as multiple treatment options exist 1

3. Overlooking SSTR PET for diagnosis and treatment planning

   • SSTR PET provides superior detection sensitivity compared to MRI alone and should be used when tumor extension or recurrence diagnosis is unclear 1

4. Failing to consider PRRT for appropriate candidates

   • Despite being investigational, PRRT shows encouraging results for treatment-refractory meningioma and should be considered when other options are exhausted 1