What are the treatment options for calcified meningioma?

Treatment Options for Calcified Meningioma

Complete surgical resection is the primary treatment of choice for calcified meningiomas, with stereotactic radiosurgery (SRS) or radiation therapy (RT) reserved for residual, recurrent, or surgically inaccessible tumors. 1, 2

Diagnostic Evaluation

• MRI with contrast is the gold standard for meningioma evaluation, revealing homogeneous dural-based enhancement, dural tail, and calcifications 3
• CT scan is particularly valuable for calcified meningiomas as it better visualizes calcifications that may not be clearly seen on MRI 4
• Somatostatin receptor (SSTR) PET imaging should be considered when tumor extension is unclear or for differentiation between recurrence and post-treatment changes 3

Surgical Management

• Complete resection with removal of dural attachment is the optimal treatment for most calcified meningiomas when feasible 1, 2
• Modern surgical techniques including image-guided surgery (frameless stereotaxy) improve precision and may reduce surgical side effects 1
• For calcified spinal meningiomas, gross total resection through a posterior approach is the standard of care, with 91.5% of cases achieving this outcome 2
• Calcified meningiomas may adhere to surrounding tissues and nerves, making surgical removal challenging and requiring careful planning 2

Radiation Therapy Options

• Stereotactic radiosurgery (SRS) is an effective option for residual or recurrent calcified meningiomas, particularly those in the cavernous sinus 1
• For larger meningiomas or those with pre-existing edema, hypofractionated stereotactic radiotherapy (SRT) may have less likelihood of causing post-radiosurgical edema than single-fraction SRS 1
• External beam radiation therapy (EBRT) is indicated for WHO grade 3 (malignant) meningiomas after surgery and for subtotally resected WHO grade 2 (atypical) meningiomas 3
• SRS for cavernous sinus meningiomas has demonstrated favorable outcomes with 5-year progression-free survival rates of 86-99% and 10-year rates of 69-97% 1

Treatment Algorithm Based on Tumor Characteristics

For Accessible Calcified Meningiomas:

• Primary treatment: Complete surgical resection including dural attachment 1, 2
• Post-surgical considerations:
  • WHO grade 1: Observation if complete resection achieved 3
  • WHO grade 2/3 or incomplete resection: Consider adjuvant radiation therapy 3

For Surgically Challenging/Inaccessible Calcified Meningiomas:

• Consider primary SRS/SRT for small tumors (<3cm) in critical locations (e.g., cavernous sinus) 1
• For larger tumors, consider fractionated radiotherapy or staged approach 1
• For skull base meningiomas, specialized neurosurgical expertise is recommended 1, 4

For Recurrent Calcified Meningiomas:

• Consider repeat surgery if accessible 1
• SRS/SRT for smaller recurrences 1
• For treatment-refractory cases, consider medical therapy options such as hydroxyurea, interferon-α, or somatostatin analogues 5

Special Considerations for Calcified Meningiomas

• Calcified meningiomas are typically WHO grade I (97.4% in spinal cases) and commonly of the psammomatous subtype (50.7%) 2
• Blood loss can be significant during surgery for large calcified meningiomas, particularly in pediatric patients who have smaller blood volumes 1
• Preoperative angiography and possible embolization should be considered for extremely large tumors to minimize blood loss 1
• Most common post-surgical complication for calcified spinal meningiomas is CSF leakage 2
• Post-operative swelling may occur and should be managed with high-dose steroids, head elevation, and close neurological monitoring 6

Post-Treatment Surveillance

• For WHO grade 1 meningiomas, MRI without and with contrast every 6-12 months is recommended 3
• After achieving stable disease status (typically after 5-10 years), follow-up intervals can be extended 1
• Clinical follow-up should include routine neurological examinations and, when appropriate, ophthalmological assessment 1