Management of Meningiomas

DIAGNOSTIC TOOLS

• MRI– Dural tail, edema

• CT SCAN: – Hyperostosis, intratumoral calcifications

• ANGIOGRAPHY: – embolization is a consideration– tumor blush

DIAGNOSTIC TOOLS

• HISTOLOGY– Globular, well demarcated– Wide dural attachment– Invaginated into underlying

brain with no invasion– Cut surface: translucent

pale, homogenously reddish brown,

– Gritty– Meningioma en plaque:

occur as sheet- like extension that covers dura; does not invaginate parenchyma

WHO

GRADE HISTOLOGICAL SUBTYPE

HISTOLOGIC FEATURES

I MENINGOTHELIAL, FIBROBLASTIC, TRANSITIONAL, ANGIOMATOUS, MICROCYSTIC, SECRETORY, LYMPHOPLASMACYTIC, PSAMMOMATOUS

Does not fulfill criteria for grade II or grade III

II (ATYPICAL) CHORDOID, CLEAR CELL 4 or more mitotic cells/ 10 hpf3 or more of ff: -increased cellularity -small cells, necrosis -prominent nucleoli, sheeting -brain invasion in an otherwise Grade 1 tumor

III (ANAPLASTIC) PAPILLARY, RHABDOID 20 or more mitosis/ 10 hpfTumor cells resemble carcinoma, sarcoma or melanoma

IMMUNOCHEMISTRY

(+) Epithelial membrane antigen

(-) anti- Leu 7 antibodies

(+) progesterone, somatostatin receptors

TREATMENT OPTIONS

• SURGERY– Objective: total removal of the meningioma, dural

attachment and bone involved with the tumor– Priority: preserve and improve neurological function

• RADIOTHERAPY– Indications:

• Residual tumor left at operation• Recurrence• Tumors could not be treated surgically• Malignant histology

• OBSERVATION– Asymptomatic patients with little or no edema

in the adjacent brain areas– Patients with mild or minimal symptoms– Older patients with seizure or very slowly

progressing symptoms– Patients in whom treatment carries a

significant risk

FOLLOW- UP

• Multidisciplinary approach for patients with disabilities (e.g. diplopia, dysphasia, dysphagia)

• Regular follow-up with enhanced MRI to check for possible recurrences

• Patients who are discharged home with antiepileptic agents should be monitored

OPERATIVE MEASURES

– Steroids for at least 48 hours; longer with significant brain edema; postoperatively, tapered off over 5 days or longer

– Intravenous antibiotics before operation; 24 hours after the procedure

– Anti- convulsant medications (phenytoin, carbamazepine, valproic acid) for supratentorial operations

TYPES OF RADIATION THERAPY

• EXTERNAL- BEAM RADIATION THERAPY– 5000- 5500 cGy– Daily fractions: 180-200 cGy over 5-6 weeks– Particular care near optic nerves and

brainstem• Radiosurgery: Co- gamma unit

– Dose delivered to margin of tumor : 15-18 Gy– Proximal to optic nerves and chiasm: 9 Gy