How do you manage a 47-year-old female (F) patient with meningiomatosis and serial Magnetic Resonance Imaging (MRI) findings of meningioma recurrence?

Management of Meningiomatosis with Serial MRI Findings of Meningioma Recurrence

For a 47-year-old female with meningiomatosis and serial MRI findings of meningioma recurrence, surgical resection should be considered as first-line treatment, followed by stereotactic radiosurgery (SRS) for any residual tumor tissue. 1

Diagnostic Evaluation

• MRI without and with IV contrast remains the gold standard for evaluating meningioma recurrence, with recommended follow-up intervals based on tumor grade 2
• Somatostatin receptor (SSTR) PET imaging should be obtained to accurately assess tumor extension and differentiate recurrence from treatment-related changes 3
• SSTR PET has high sensitivity and specificity for meningioma detection and should be performed if tumor extension or recurrence diagnosis is unclear 3
• Brain MRI should be performed within 2 weeks prior to any treatment as baseline for disease monitoring and response assessment 3

Treatment Algorithm

Surgical Management

• Complete surgical resection is the treatment of choice when feasible, as it offers the best chance for long-term control 1
• The extent of resection should be maximized while preserving neurological function 4
• Surgical planning should incorporate SSTR PET findings to better delineate tumor extent, particularly for bone involvement 3

Radiation Therapy Options

• For residual or recurrent tumor after surgery:
  • SRS is preferred for smaller residual tumors (typically <3-4 cm) 2
  • Fractionated stereotactic radiotherapy (SRT) should be considered for larger tumors or those near critical structures 2
  • SRS offers higher rates of tumor shrinkage compared to SRT (53% vs 29%) 2

Advanced Treatment Options

• For treatment-refractory cases with positive SSTR expression on PET imaging, peptide receptor radionuclide therapy (PRRT) may be considered 3
• PRRT eligibility criteria include:
  • Positive somatostatin receptor expression on SSTR PET imaging within the last 2 months 3
  • Karnofsky performance status above 60% or ECOG 0-2 3
  • No contraindications such as compromised renal function (GFR <40 ml/min/1.73 m²) or bone marrow function 3

Follow-up Protocol

• For WHO grade 1 meningiomas, MRI surveillance should be performed every 6-12 months 2
• For higher-grade or recurrent meningiomas, more frequent imaging (every 3-6 months) is recommended 2
• SSTR PET imaging should be repeated to assess treatment response, particularly after PRRT 3
• After SRS or radiotherapy, imaging follow-up at 1 month and then every 2-3 months for the first year is recommended 3

Special Considerations for Meningiomatosis

• Meningiomatosis represents a challenging clinical scenario with multiple meningiomas that may require different treatment approaches for each lesion 5
• Treatment planning should prioritize symptomatic or rapidly growing lesions 6
• Asymptomatic lesions may be observed with serial imaging, as many show minimal or no growth over years 6
• For patients with multiple recurrent lesions, systemic therapy may be considered, though evidence for efficacy is limited 1

Pitfalls and Caveats

• Differentiation between true tumor recurrence and treatment-related changes can be challenging; SSTR PET is valuable in this distinction 3
• Bevacizumab may be effective for radiation necrosis but has shown mixed results for tumor control in meningiomas 7
• When interpreting SSTR PET, be aware that other lesions (inflammatory, neoplastic) may also show increased uptake 3
• Patients with meningiomatosis require lifelong surveillance due to the risk of recurrence or development of new lesions 4