Treatment Options for Brain Meningioma
Complete surgical resection is the treatment of choice for most brain meningiomas, with additional treatment options including observation, radiation therapy, and in select cases, peptide receptor radionuclide therapy (PRRT). 1, 2
Initial Assessment and Diagnosis
- MRI with contrast is the standard diagnostic imaging modality for meningiomas, providing detailed characterization of the lesion and surrounding structures 1, 2
- Typical MRI features include homogeneous dural-based enhancement, presence of a dural tail, CSF cleft between tumor and brain, and possible intratumoral calcifications 1, 2
- Somatostatin receptor (SSTR) PET imaging should be considered when tumor extension is unclear or for differentiation between recurrence and post-treatment changes 1
Treatment Decision Algorithm Based on Tumor Characteristics
Small Meningiomas (<30 mm)
- Asymptomatic: Observation is preferred, or surgery if accessible and potential neurological consequences exist 1
- Symptomatic: Surgery if accessible, followed by radiation therapy (RT) if WHO grade 3 or if incomplete resection 1
Large Meningiomas (≥30 mm)
- Asymptomatic: Surgery if accessible, followed by RT if WHO grade 3 or consider RT if incomplete resection and WHO grade 1/2 1
- Symptomatic: Surgery if accessible, followed by RT if WHO grade 3 or consider RT if incomplete resection and WHO grade 1/2 1
Surgical Management
- Complete resection of meningiomas with removal of dural attachment is the optimal treatment when feasible 1, 3
- Modern surgical techniques including image-guided surgery (frameless stereotaxy) improve precision and may reduce surgical side effects 1
- Special considerations for complex locations:
- Skull base, cavernous sinus, and petrous bone meningiomas may require specialized neurosurgical expertise 1, 2
- Intraventricular meningiomas require careful surgical planning and consideration of approach 1
- For pediatric patients, joint procedures by pediatric neurosurgeons and skull base specialists are recommended 1
Radiation Therapy Options
- External beam radiation therapy (EBRT) is indicated for:
- Stereotactic radiosurgery (SRS) can be used for smaller tumors or as an alternative to surgery in high-risk patients 4, 6
- Radiation planning should consider tumor location and proximity to critical structures 4
Advanced Treatment Options
- Peptide receptor radionuclide therapy (PRRT) using radiolabeled somatostatin receptor ligands (primarily [177Lu]Lutetium and [90Y]Yttrium) shows promising results for treatment-refractory meningiomas 1
- SSTR PET imaging should be performed prior to PRRT to confirm target expression 1
- PRRT is currently not FDA or EMA approved for meningiomas but may be considered in clinical trials for refractory cases 1
Post-Treatment Surveillance
- For WHO grade 1 meningiomas, MRI without and with contrast every 6-12 months is recommended 1
- WHO grade 2 and 3 meningiomas require more frequent follow-up 1
- SSTR PET may be useful in distinguishing tumor recurrence from post-treatment changes 1
Special Considerations and Pitfalls
- Not all enhancing dural-based lesions are meningiomas; differential diagnosis includes metastases, gliomas, and primary CNS lymphoma 2, 7
- Blood loss during surgery is a significant concern, particularly for large or intraventricular tumors 1, 2
- Some tumors may be too difficult or dangerous to remove completely due to involvement of vital neural structures or major vessels 1
- Molecular and genetic features are increasingly important in predicting aggressive behavior and may guide treatment decisions 7