What are the treatment options for meningioma aside from surgery?

Treatment Options for Meningioma Beyond Surgery

Stereotactic radiosurgery (SRS) is the most effective non-surgical treatment option for meningioma, with 10-year progression-free survival rates of 85-100% for WHO grade I meningiomas. 1

Primary Radiation Treatment Options

• SRS is recommended as a primary treatment for many benign intracranial meningiomas (recommendation level II), particularly for patients who are not surgical candidates or have tumors in surgically challenging locations 1
• Marginal doses of 12-15 Gy in a single fraction are generally sufficient for durable local control of WHO grade I meningiomas 1
• Hypofractionated stereotactic radiotherapy (HSRT) may be used for selected cases, with a common schedule of 25 Gy in 5 fractions 1
• For larger meningiomas (>3 cm) or those with pre-existing edema, fractionated stereotactic radiotherapy is preferred over single-fraction SRS 2, 3
• External beam radiation therapy (EBRT) is indicated for WHO grade 3 (malignant) meningiomas and subtotally resected WHO grade 2 (atypical) meningiomas 3

Factors Affecting Treatment Selection

• Tumor size (<3 cm is ideal for SRS) 2, 3
• Tumor location (proximity to critical structures) 3
• Previous surgical intervention (may adversely affect tumor control with subsequent SRS) 1
• WHO grade (higher grades require more aggressive treatment approaches) 3
• Patient-specific factors (age, comorbidities, symptoms) 3, 4

Surveillance Approach

• For asymptomatic small meningiomas (<30 mm), observation with regular MRI surveillance is appropriate 3, 4
• MRI follow-up should be performed every 6-12 months initially 3, 4
• After achieving stable disease status (typically 5 years), follow-up intervals can be extended 3, 4

Advanced Treatment Options for Refractory Cases

• Peptide receptor radionuclide therapy (PRRT) using radiolabeled somatostatin receptor ligands shows promise for treatment-refractory meningiomas 3
• Somatostatin receptor (SSTR) PET imaging should be performed prior to PRRT to confirm target expression 3
• Limited data suggests hydroxyurea may have modest success in recurrent meningiomas 5, 6
• Hormonal therapy has been explored for meningiomas expressing progesterone receptors, though with limited evidence 6

Treatment Efficacy and Outcomes

• SRS provides 10-year local control rates ranging from 71% to 100% for benign meningiomas 1
• 10-year progression-free survival rates range from 55% to 97% with SRS 1
• Toxicity rates with SRS are generally low, with rare events of post-treatment deterioration 1
• Complete surgical resection remains the gold standard when feasible, but SRS offers comparable tumor control for appropriately selected patients 1

Pitfalls and Caveats

• Previous surgery may adversely affect tumor control with subsequent SRS, possibly due to complex target volume definition or more aggressive tumor biology 1
• The literature lacks class I and II evidence for SRS in meningioma treatment, though there is strong consensus from class III evidence studies 1
• Radiation therapy carries a theoretical risk of inducing malignancy, though this appears to be rare based on available data 1
• For cavernous sinus meningiomas specifically, surgery is not recommended, and radiosurgery may be helpful for symptomatic growing tumors 1