Treatment Approach for Calcified Meningioma
Complete surgical resection is the optimal treatment for calcified meningiomas when feasible, with removal of the dural attachment to achieve the best outcomes. 1, 2
Diagnostic Evaluation
- MRI with contrast is the gold standard for meningioma evaluation, revealing homogeneous dural-based enhancement, dural tail, and possible calcifications 2
- CT scan is particularly valuable for calcified meningiomas as it better visualizes calcifications that may not be clearly seen on MRI 1
- Somatostatin receptor (SSTR) PET imaging should be considered when tumor extension is unclear or for differentiation between recurrence and post-treatment changes 3
Treatment Algorithm
Surgical Management
- Complete surgical resection including dural attachment is the primary treatment option for most calcified meningiomas 1, 2
- Calcified meningiomas are more likely to adhere to nerves and dura, increasing the risk of neurological dysfunction and CSF leakage after surgery 4
- Precise tumor resection, meticulous dura repair during surgery, and careful post-operative care are critical for achieving acceptable outcomes 4
- Blood loss can be significant during surgery for large calcified meningiomas; preoperative angiography and possible embolization should be considered 1
Radiation Therapy Options
- For residual or recurrent tumor after surgery, stereotactic radiosurgery (SRS) is preferred for smaller tumors (typically <3-4 cm) 3, 1
- For larger meningiomas or those with pre-existing edema, hypofractionated stereotactic radiotherapy (SRT) may have less likelihood of causing post-radiosurgical edema 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% 3
Observation
- Asymptomatic small calcified meningiomas may be observed with regular imaging follow-up 3, 5
- Radiological surveillance is a valid option for low-grade asymptomatic meningiomas 5
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, Karnofsky performance status above 60%, and adequate renal and bone marrow function 3, 6
Special Considerations for Calcified Meningiomas
- Greater degree of spinal canal stenosis from calcified meningiomas correlates with poorer outcomes 4
- Post-operative swelling may occur and should be managed with high-dose steroids, head elevation, and close neurological monitoring 1
- Calcified spinal meningiomas most commonly occur in the thoracic spine (82%) and are predominantly found in females (90.4%) 7
Post-Treatment Surveillance
- For WHO grade 1 meningiomas, MRI without and with contrast every 6-12 months is recommended 1, 2
- After achieving stable disease status (typically after 5-10 years), follow-up intervals can be extended 3
- Clinical follow-up should include routine neurological examinations and, when appropriate, ophthalmological assessment 3
- SSTR PET imaging is valuable for distinguishing tumor recurrence from post-treatment changes 3, 6
Pitfalls and Caveats
- CT and MRI with contrast enhancement are recommended before surgery to identify calcification 4
- Calcified meningiomas can be surgically challenging due to adherence to surrounding structures; specialized neurosurgical expertise is recommended 1, 7
- The postradiotherapy MRI should be considered the "new baseline" rather than the postsurgical MRI for ongoing surveillance 2