What are the management options for meningioma?

Management Options for Meningioma

Complete surgical resection is the primary treatment of choice for symptomatic meningiomas, with adjuvant radiotherapy reserved for specific cases based on tumor grade, location, and extent of resection. 1

Diagnostic Approach

• MRI with contrast is the standard investigation for meningiomas
• Typical imaging features:
  • Isointense/hypointense on T1-weighted MRI
  • Hyperintense on T2-weighted MRI
  • Strong uniform contrast enhancement
  • Characteristic "dural tail sign" (though not pathognomonic)
  • Possible calcifications (up to 50% in children) and cystic transformation

Management Algorithm

1. Observation

• Appropriate for:
  • Asymptomatic, incidentally discovered meningiomas
  • Elderly patients with significant comorbidities
  • Slow-growing tumors
• Requires regular MRI surveillance (annually for at least 10 years) 1
• Caution: Even benign meningiomas can recur up to 20% within 25 years, indicating need for long-term follow-up

2. Surgical Management

• First-line treatment for symptomatic meningiomas 1, 2
• Complete resection including dural attachment is optimal
• Surgical approach determined by:
  • Tumor location (supratentorial, intraventricular, skull base)
  • Size
  • Proximity to critical structures
• Modern techniques to consider:
  • Image-guided neuronavigation
  • Intraoperative electrophysiological monitoring (especially for tumors near cranial nerves)
  • Preoperative angiography and possible embolization for large tumors with risk of significant blood loss

3. Radiotherapy Options

• Indications for adjuvant radiotherapy: 1, 3

  • WHO grade II/III tumors
  • Subtotal resection with residual tumor
  • Multiple recurrences
  • Brain invasion or extensive invasion of other tissues
  • Contraindication to surgery

• Conventional Radiotherapy:

  • Dose: 50-55 Gy in conventional fractionation
  • Higher doses (up to 60 Gy) only for WHO grade III meningiomas
  • Margins: 0.5-1.0 cm for benign/atypical meningiomas; 1.0-1.5 cm for anaplastic meningiomas

• Stereotactic Radiosurgery/Radiotherapy:

  • Suitable for smaller tumors
  • Particularly useful for tumors in critical locations (optic sheet, cavernous sinus) 4
  • Consider referral to specialized centers with experience in stereotactic techniques

4. Special Considerations by Tumor Grade

WHO Grade I (Benign) - ~80% of cases: 2, 5

• Complete surgical resection if feasible and safe
• Observation may be appropriate for asymptomatic cases
• SRS/SRT as primary treatment for surgically challenging locations

WHO Grade II (Atypical) - 5-20% of cases: 3, 5

• Aggressive surgical resection
• Adjuvant radiotherapy recommended (conventionally fractionated RT to at least 59.4 Gy)
• 10-year survival rate ~60%

WHO Grade III (Anaplastic) - 1-3% of cases: 2, 5

• Aggressive surgical resection when possible
• Adjuvant radiotherapy strongly recommended
• Poor prognosis (10-year survival ~15%)

Special Considerations

Skull Base Meningiomas

• Higher surgical risk due to proximity to critical structures
• Consider combined approach with neurosurgeon specialized in skull base surgery
• Stereotactic radiotherapy may be preferred for locations like cavernous sinus 4

Intraventricular Meningiomas

• Require careful surgical planning
• Approaches may include interhemispheric/transcallosal or transcortical/transventricular routes
• Higher risk of significant blood loss during surgery

Pediatric Meningiomas

• Rare but require special consideration
• More likely to have unusual locations (intraventricular, parasellar)
• Balance between radiotherapy toxicity on developing brain versus risk of recurrence
• Genetic screening recommended (NF-2 often presents years after meningioma diagnosis) 1

Treatment Pitfalls to Avoid

1. Underestimating recurrence risk: Even completely resected benign meningiomas can recur within 25 years, necessitating long-term follow-up

2. Inadequate resection of dural attachment: Higher recurrence rates occur when dural attachment is left behind 1

3. Overlooking genetic syndromes: All pediatric patients should be referred for genetic screening (particularly for NF-2) 1

4. Excessive blood loss during surgery: Consider preoperative embolization for large tumors, especially in pediatric patients where blood loss has proportionally greater impact 1

5. Inappropriate radiotherapy timing: For WHO grade II/III tumors, adjuvant radiotherapy should be considered even after complete resection due to higher recurrence risk 3, 5

6. Lack of multidisciplinary approach: Complex cases benefit from discussion between neurosurgeons, radiation oncologists, and other specialists to determine optimal treatment strategy 1