Initial Approach to Treating a Patient Diagnosed with a Meningioma
The initial approach to treating a patient diagnosed with a meningioma should be based on tumor characteristics, with complete surgical resection being the optimal treatment when feasible, followed by observation for WHO grade 1 tumors or adjuvant radiation therapy for WHO grade 2/3 or incompletely resected tumors. 1, 2
Diagnostic Evaluation
- MRI with contrast is the gold standard for evaluating meningiomas, providing detailed characterization including homogeneous dural-based enhancement, dural tail, and relationship to surrounding structures 1
- CT scan provides complementary information, particularly for calcified meningiomas, as it better visualizes calcifications that may not be clearly seen on MRI 3
- Somatostatin receptor (SSTR) PET imaging should be considered when tumor extension is unclear or for differentiation between recurrence and post-treatment changes 4, 1
Treatment Algorithm Based on Clinical Presentation
Asymptomatic Small Meningiomas (<3 cm)
- Observation with regular MRI surveillance is appropriate for small asymptomatic meningiomas without significant mass effect 5, 1
- Follow-up MRI should be performed every 6-12 months initially 1
- Consider intervention if growth is documented or symptoms develop 3
Symptomatic Meningiomas or Large Tumors
- Complete surgical resection including dural attachment is the optimal treatment when feasible 5, 2
- Modern surgical techniques including image-guided surgery improve precision and may reduce surgical side effects 3
- For tumors in critical locations (e.g., skull base, cavernous sinus) where complete resection carries high risk, a combination of subtotal resection followed by radiation therapy should be considered 3, 1
Treatment Based on WHO Grade
WHO Grade 1 (Benign) Meningiomas
- Complete surgical resection is often curative 2, 6
- Observation is appropriate after complete resection 1
- For incompletely resected tumors, options include:
WHO Grade 2 (Atypical) Meningiomas
- Complete surgical resection should be attempted when feasible 8
- Adjuvant radiation therapy is recommended for subtotally resected WHO grade 2 meningiomas 1, 8
- Conventionally fractionated radiation therapy to at least 59.4 Gy is considered standard of care 8
WHO Grade 3 (Malignant) Meningiomas
- Aggressive surgical resection followed by external beam radiation therapy is indicated 1, 2
- Close surveillance is essential due to higher recurrence rates 2
Special Considerations
- For meningiomas located at the skull base or involving venous sinuses, specialized neurosurgical expertise is recommended 3
- Blood loss can be significant during surgery for large or highly vascular meningiomas 5
- Post-operative swelling may occur and should be managed with high-dose steroids, head elevation, and close neurological monitoring 5
Advanced Treatment Options
- For treatment-refractory meningiomas, peptide receptor radionuclide therapy (PRRT) using radiolabeled somatostatin receptor ligands shows promising results 4
- SSTR PET imaging should be performed prior to PRRT to confirm target expression 4
- Eligibility criteria for PRRT include:
Post-Treatment Surveillance
- MRI without and with contrast every 6-12 months is recommended for follow-up 5, 1
- 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 3
- SSTR PET may be useful in distinguishing tumor recurrence from post-treatment changes 4, 1