What are the next steps for a patient with a right posterior frontal meningioma (tumor) with mass effect noted on brain Magnetic Resonance Imaging (MRI)?

From the Guidelines

The next steps for a right posterior frontal meningioma with mass effect on brain MRI should include neurosurgical consultation for potential surgical resection. This is particularly important when mass effect is present, as it indicates the tumor is compressing surrounding brain tissue, which can lead to neurological symptoms 1. Prior to surgery, additional imaging studies such as CT angiography may be needed to evaluate blood vessel involvement. Complete preoperative assessment including neurological examination, seizure history evaluation, and baseline cognitive testing should be performed. Dexamethasone (typically 4-8mg every 6 hours) may be prescribed to reduce peritumoral edema and associated symptoms while awaiting definitive treatment. Anticonvulsant medication such as levetiracetam (500-1000mg twice daily) might be indicated if seizures have occurred or if the tumor location poses high seizure risk.

For patients who are poor surgical candidates, alternative treatments such as stereotactic radiosurgery or fractionated radiotherapy may be considered. The management approach depends on tumor size, location, patient's symptoms, age, and overall health status. While many meningiomas are benign (WHO grade I), complete resection offers the best chance for cure and prevention of recurrence when safely achievable. Recent studies have also highlighted the potential of theranostic concepts using radiolabeled somatostatin receptor ligands for diagnostics and therapy of meningiomas, although more research is needed to fully establish their efficacy 2.

Key considerations in the management of meningiomas include:

• Tumor size and location
• Presence of mass effect or neurological symptoms
• Patient's overall health status and age
• Potential for complete surgical resection
• Alternative treatment options such as radiosurgery or radiotherapy
• Use of dexamethasone and anticonvulsant medication as needed. Neurosurgical consultation is essential to determine the best course of treatment for each individual patient.

From the Research

Diagnosis and Treatment Options

The diagnosis of a right posterior frontal meningioma with mass effect noted on brain MRI can be approached through various methods, including:

• Neuroimaging, mostly magnetic resonance imaging (MRI), for a provisional diagnosis 3
• Surgical intervention with tissue for the definitive diagnosis according to the WHO classification 3
• Molecular profiling, including gene panel sequencing and genomic methylation profiling, for a more accurate diagnosis and prognosis 4, 3

Treatment Approaches

Treatment options for meningiomas include:

• Watch-and-scan strategy for asymptomatic or elderly patients 3
• Gross total surgical resection, including the involved dura, which is often curative 3
• Radiosurgery, if the size or vicinity of critical structures allows it 5, 3
• Fractionated radiotherapy (RT) for inoperable or recurrent tumors 5, 3
• Treatment concepts combining surgery and radiosurgery or fractionated RT, although timing, type, and dosing of RT approaches remain controversial 3

Considerations for Treatment

When considering treatment options, factors such as:

• Tumor size and location 6
• Patient's age and overall health 3
• Presence of symptoms and neurocognitive deficits 6
• Molecular characteristics and genomic aberrancies 4 should be taken into account to determine the best course of treatment.