What are the treatment options for meningioma?

Treatment Options for Meningioma

Surgical resection is the primary treatment of choice for most meningiomas, with postoperative radiotherapy considered based on extent of resection and histological grade. 1

Initial Treatment Approach

Surgical Management

• First-line treatment: Complete surgical resection including dural attachment is the treatment of choice for symptomatic meningiomas 2
• Surgical approach is determined by:
  • Tumor location
  • Size
  • Proximity to critical structures 2
• Goals of surgery:
  • For parasagittal, lateral sphenoid wing, and olfactory groove meningiomas: gross-total resection 3
  • For tumors in eloquent areas or surgically inaccessible locations: subtotal resection to preserve neurological function 3
• Preoperative embolization may be considered for large tumors to reduce intraoperative bleeding 2

Radiation-Based Treatments

• Stereotactic radiosurgery (SRS):

  • Recommended for small (<3 cm) well-circumscribed tumors 2
  • Excellent option for post-operative residual tumor in cavernous sinus 2
  • 5-year progression-free survival rates: 86-99% 2
  • 10-year progression-free survival rates: 69-97% 2
  • Typical prescription dose: 12-15 Gy in a single fraction 1

• Fractionated stereotactic radiotherapy (SRT):

  • Suitable for larger tumors (>3-3.5 cm) or those with brainstem extension 2, 4
  • Conventional dose: 50-55 Gy in standard fractionation 2
  • 5-year tumor control rates >90% for benign meningiomas 4

Treatment Selection Based on Tumor Characteristics

WHO Grade 1 Meningiomas (75-80% of cases)

1. Complete surgical resection if achievable with minimal morbidity 5
2. SRS/SRT for:
   • Small, surgically inaccessible tumors
   • High-risk surgical patients
   • Elderly patients 5
   • Residual tumor after subtotal resection 2

WHO Grade 2/3 Meningiomas (20-25% of cases)

1. Surgical resection when possible
2. Adjuvant radiotherapy recommended for:
   • All WHO grade 2/3 tumors
   • Subtotal resection with residual tumor
   • Multiple recurrences
   • Brain invasion
   • Extensive invasion of other tissues
   • Contraindication to surgery 2

Special Considerations

Recurrent or Progressive Meningiomas

• Local therapies are commonly recommended:
  • Further surgical resection
  • Salvage radiotherapy 1
• Systemic therapies have been investigated but none are established as management standards 1
• Peptide receptor radionuclide therapy (PRRT) is an investigational treatment for recurrent cases with positive somatostatin receptor expression 2
• Hydroxyurea has shown modest success in patients with recurrent meningiomas 5, 6

Asymptomatic or Incidental Meningiomas

• Observation with regular MRI surveillance is appropriate for:
  • Asymptomatic, incidentally discovered meningiomas
  • Elderly patients with significant comorbidities
  • Slow-growing tumors 2
  • Annual MRI surveillance recommended for at least 10 years 2

Follow-up Recommendations

• WHO grade 1 tumors: MRI without and with IV contrast every 6-12 months 2
• WHO grade 2/3 tumors: More frequent follow-up needed 2
• Long-term surveillance is necessary as even benign meningiomas can recur within 25 years 2

Potential Pitfalls

• Underestimating recurrence risk: Even completely resected benign meningiomas can recur within 25 years 2
• Inadequate resection of dural attachment: Can lead to higher recurrence rates 2
• Overlooking genetic syndromes: Particularly NF-2 in pediatric patients 2
• Delaying adjuvant radiotherapy: For WHO grade 2/3 tumors can lead to higher recurrence risk 2
• Inappropriate treatment selection: SRS is not suitable for tumors >3 cm or those close to critical structures like optic chiasm 4

By following this evidence-based approach to meningioma treatment, clinicians can optimize outcomes while minimizing morbidity and mortality for patients with these common intracranial tumors.