Treatment Options for Meningioma
Complete surgical resection is the primary treatment of choice for symptomatic meningiomas, with observation recommended for asymptomatic incidental meningiomas and radiotherapy reserved for specific cases based on tumor grade, location, and extent of resection. 1
Diagnostic Approach
- MRI brain without and with IV contrast is the gold standard imaging modality for meningiomas 2
- Typical MRI features include:
- Homogeneous dural-based enhancement
- Presence of a dural tail
- CSF cleft between tumor and brain
- Possible intratumoral calcifications (best visualized with SWI)
- Possible vasogenic edema in subjacent parenchyma 2
Treatment Algorithm
1. Observation/Surveillance
Appropriate for:
- Asymptomatic, incidentally discovered meningiomas
- Elderly patients with significant comorbidities
- Slow-growing tumors 1
Surveillance protocol:
- Regular MRI surveillance for at least 10 years
- More than 60% of asymptomatic meningiomas will not grow in size 3
- Radiological characteristics associated with low growth rate include calcifications and hypointense regions on T2-weighted MRI 3
2. Surgical Resection
Indications:
- Symptomatic meningiomas
- Large or growing asymptomatic meningiomas
- Tumors in locations that may produce neurological deficits 1, 2
Surgical considerations:
- Complete resection including dural attachment is optimal
- Surgical approach determined by tumor location, size, and proximity to critical structures
- Modern techniques to consider:
- Image-guided neuronavigation
- Intraoperative electrophysiological monitoring
- Preoperative angiography with possible embolization for large tumors 1
Outcomes:
- Complete resection rates of 55-79% have been reported in pediatric patients 2
- Complete resection is often curative for benign meningiomas 4
- Even with complete resection, up to 20% of benign meningiomas may recur within 25 years 2
3. Radiotherapy Options
Indications:
- WHO grade II/III tumors
- Subtotal resection with residual tumor
- Multiple recurrences
- Brain invasion or extensive invasion of other tissues
- Contraindication to surgery 1
Types of radiotherapy:
- Conventional radiotherapy: 50-55 Gy in conventional fractionation (higher doses for WHO grade III)
- Stereotactic radiosurgery (SRS): For cavernous sinus meningiomas and other selected cases 2
- Fractionated stereotactic radiotherapy (SRT): For larger tumors or those with brainstem extension 2
Outcomes:
- After SRS, 5-year progression-free survival rates range from 86% to 99%
- 10-year progression-free survival rates range from 69% to 97%
- Post-SRS neurological preservation rates range from 80% to 100% 2
4. Novel Therapeutic Approaches
For recurrent or unresectable tumors when surgery and radiotherapy have failed:
- Targeted radionuclide therapy using radiolabeled somatostatin receptor ligands for SSTR-positive meningiomas 2
- Hormonal therapy or chemotherapy (limited data, hydroxyurea has shown modest success) 4
- Molecular testing for targeted therapy selection (recommended at recurrence rather than initial diagnosis) 2
Special Considerations
Pediatric Patients
- Higher risk of unusual locations and recurrence
- Genetic screening recommended, particularly for NF-2 1
- Complete resection rate of 62% and partial resection in 33% reported 2
Cavernous Sinus Meningiomas
- Challenging location for surgical resection
- SRS and SRT approaches have favorable therapeutic impact with minimal complications
- SRS offers higher rate of tumor shrinkage (53%) compared to SRT (29%) 2
Common Pitfalls to Avoid
- Underestimating recurrence risk even for completely resected benign meningiomas 1
- Inadequate resection of dural attachment leading to higher recurrence rates 1
- Overlooking genetic syndromes, especially in pediatric patients 1
- Excessive blood loss during surgery (consider preoperative embolization for large tumors) 1
- Delaying adjuvant radiotherapy for WHO grade II/III tumors 1
- Failing to establish a new baseline MRI after radiotherapy (important for accurate follow-up) 2
By following this algorithmic approach to meningioma management, clinicians can optimize outcomes while minimizing morbidity and mortality for patients with these common intracranial tumors.