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Meningioma For Surgeons 080613

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Elizabeth Kuhn

on 8 August 2013

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Transcript of Meningioma For Surgeons 080613

Epidemiology and Grading
~8600 cases/yr
Most common primary intracranial neoplasm (30% of all brain primaries)
Most common secondary tumor
Peak incidence 50s-60
Overall F>M 2:1
Genetic association with NF-2 (22q12)
Originate from arachnoid cap cells
Symptoms, if present, are related to location, edema and/or mass effect
Special Cases
by EB Kuhn
August 6, 2013

WHO Classification
Grade I (~70%)
Grade III (1-2%)
Grade II (~30%)
Rare mitoses (<4/10hpf)

Any variant other than clear cell, chordoid, papillary, or rhabdoid

Does not fulfill criteria for grade II or III
Mawrin C and Perrie A. Pathological classification and molecular genetics of meningiomas. 2010. Journal of Neuro-Oncology. 99(3):379-391
WHO Grade I
Mawrin C and Perrie A. Pathological classification and molecular genetics of meningiomas. 2010. Journal of Neuro-Oncology. 99(3):379-391
WHO Grade II
Frequent mitoses (>= 4/10hpf)

3 or more: sheeting architecture, hypercellularity, prominent nucleoli, small cells with high N:C ratio, foci of necrosis

Chordoid, clear cell, or brain invasion
Mitoses >= 20/10 hpf

Focal or diffuse loss of meningothelial differentiation

Papillary or rhabdoid
Mawrin C and Perrie A. Pathological classification and molecular genetics of meningiomas. 2010. Journal of Neuro-Oncology. 99(3):379-391
Backer-Grondahl T, Moen BH, and Torp SH. The histopathological spectrum of human meningiomas. 2012. Int J Clin Exp Pathol. 5(3):231-242
Radiation-Induced Meningiomas
Spinal Meningiomas
More likely to be multifocal and atypical/malignant
Latency period inversely proportional to age at initial radiation (range 2-63 years)
Treatment: surgery or SRS
SRS failure associated with tumor volume
(10.7cc vs 2.2cc, p = 0.028)
Most common benign intradural, extramedullary tumor
25-50% of all spinal cord tumors in adults
Female predominance, 80% in thoracic spine, associated with NF
Conventional laminectomy, hemilaminectomy or partial hemilaminectomy (Iacoangeli et al 2012)
Complete resection: 9.7% recurrence at mean 12.2 yrs
Incomplete resection: 100% recurrence at mean 5 yrs
(Nakamura et al 2012)

SRS (Sachdev et al 2011)
103 benign spinal tumors (32 meningiomas, 24 neurofibromas, 47 schwannomas)
Mean followup 33 mos
Mean prescription dose 19.4 Gy
Clinical control 91% for meningiomas at last followup
1 patient developed treatment-related transverse myelitis 9 mos after SRS
SRS Toxicity
Kuhn EN, et al. ASTRO 2013 abstract. Unpublished data.
Comparison of early complications for patients with convexity and parasagittal meningiomas treated with either stereotactic radiosurgery or fractionated stereotactic radiotherapy.
Girvigian et al. 2008. Neurosurgery. 52(5 Suppl):A19-27; discussion A27-28.
Group A (SRS)
n = 14
Med followup: 20 mos
Med tumor volume: 2.8 cc
Med margin dose: 14 Gy
6/14 pts (43%) developed symptomatic peritumoral edema
Group B (fractionated RT)
n = 16
Med followup: 18 mos
Med tumor volume: 7.5 cc
50.4 Gy in 28 fx (6 pts)
25 Gy in 5 fx (10 pts)
1/16 pts (6%) developed symptomatic peritumoral edema
Group A had smaller tumors (p=0.0008)
Group A had a higher rate of peritumoral edema (p=0.031)
Larger tumor volume (p=0.0014) and margin dose >14 Gy (p=0.031) associated with onset of symptomatic peritumoral edema
1 - Asymptomatic or mild symptoms; intervention not indicated
2 - Moderate; limiting ADLs; minimal, local or non-invasive intervention
3 - Severe or medically significant; disabling; invasive intervention
4 - Life-threatening; urgent intervention required
5 - Death related to adverse effect
CTCAE Toxicity Grading Criteria
194 pts received GKRS for meningioma
43 pts, 22% experienced a toxicity event
23 pts, 12% experienced a Grade 2 or higher (significant) toxicity event
Predictors of significant toxicity
tumor volume (adjusted odds ratio = 1.02, p<0.001)
pre-treatment edema (adjusted odds ratio = 3.55, p<0.05)
volume receiving 12 Gy (adjusted odds ratio = 1.03, p<0.05)
Prior EBRT predictive of any toxicity (adjusted odds ratio = 2.66, p<0.05)
Modified from Donald Simpson, J Neurol Neurosurg Psychiat. 1957. 20:22-39.
Chan et al. Benign Brain Tumors: Meningiomas and Vestibular Schwannomas. In: Gunderson LL and Tepper JE. Clinical Radiation Oncology. 3rd ed. Philadelphia, PA: Saunders; 2012; 473-492.
Definition of Resection Extent




Macroscopically complete removal of tumor, with excision of its dural attachments and any abnormal bone
Macroscopically complete removal of tumor, with coagulation of its dural attachments
Macroscopically complete removal of tumor, without resection or coagulation of dural attachments, or of extradural extensions
Partial removal, leaving tumor in situ
Simple decompression or biopsy




Stafford et al. Primarily Resected Meningiomas: Outcome and Prognostic Factors in 581 Mayo Clinic Patients, 1978 Through 1988. 1998. Mayo Clin Proc. 73:936-942
Median fu: 9.0 years

Condra et al. Benign menigiomas: primary treatment selection affects survival. 1997. IJROBP. 39(2):427-436
n=382, treated from 1964-1992
Median fu: 8.2 yrs

Not randomized
Surgery alone: n=229
76% had GTR -> 15 yr LC 76%
24% had STR -> 15 yr LC 30%
Surgery + RT: n=17
15 yr LC 87%
Korah et al. Radiation therapy alone for imaging-defined meningiomas. 2010. IJROBP. 76(1):181-186.

Litre et al. Fractionated stereotactic radiotherapy treatment of cavernous sinus meningiomas: A study of 100 cases. 2009. IJROBP. 74(4): 1012-1017.

Turbin et al. A long-term visual outcome comparison in patients with optic nerve sheath meningioma managed with observation, surgery, radiotherapy, or surgery and radiotherapy. 2002. Ophthalmology. 109(5): 890-899
GTR +/- post op RT
STR + post op RT
SRS to 14 Gy
XRT to 54-60 Gy
STR +/- post op RT
Definitive RT
SRS to 12-14 Gy
XRT 50-54 Gy
Consider post-op radiation if:
- WHO Grade III
- WHO Grade II
- Subtotal resection
Aghi et al. Long-term recurrence rates of atypical meningiomas after gross total resection with or without postoperative adjuvant radiation. 2009. Neurosurgery. 64(1):56-60; discussion 60.

Attia et al. Patterns of failure after treatment of atypical meningioma with Gamma Knife radiosurgery. 2012. J Neurooncol. 108:179-185.

Palma et al. Long-term prognosis for atypical and malignant meningioma: a study of 71 surgical cases. 1997. J Neurosurg. 86(5):793-800.
GTR: Simpson I-III
GTR (80%) vs STR (20%)
5 yr PFS 87.8% vs 61.4%
10 yr PFS 75.3% vs 38.6%
Kondziolka et al. Long-term outcomes after meningioma radiosurgery: physician and patient perspectives. 1999. J Neurosurg. 91:44-50.
99 consecutive pts at Univ of Pittsburgh had SRS for meningiomas from 1987-1992
Mean margin dose: 16 Gy
Serial imaging, clinical evals and patient survey 5-10 yrs after treatment
63% of tumors shrunk, 32% were unchanged, and 5% enlarged
93% clinical control rate (no resection required)
New neurologic deficits in 5 pts (5%), 3-31 mos post-treatment
Stafford et al. Meningioma radiosurgery: Tumor control, outcomes and complications among 190 consecutive patients. 2001. Neurosurgery. 49(5):1029-1037.
Median followup: 47 mos
Median margin dose: 16 Gy
5 yr LC: 93% (benign), 68% (atypical), 0% (malignant)

24 pts (13%) developed treatment-related complications; median 6 mos after treatment

Prognostic factors for poor LC: prior surgery or EBRT, atypical/malignant histology, location other than cranial base, increasing tumor volume
Pollock et al. Single-fraction radiosurgery of benign intracranial meningiomas. 2012. Neurosurg. 71:604-613.
Retrospective review of 416 pts with SRS for imaging-defined or confirmed WHO Grade I meningiomas
Median margin dose: 16 Gy
Local control: 96% at 5 yr, 89% at 10 yr
45 pts (11%) had permanent radiation-related complications; median 9 mos after SRS
Kuhn et al. Patterns of failure after Gamma Knife stereotactic radiosurgery for treatment of meningiomas. 2013. Neurosurgical Focus. Under review.
279 pts treated from 1999-2011, all grades
Median followup: 35.8 mos, median margin dose: 12 Gy
Local control 81% at 5 yrs
Grade II/III (adjusted OR 16.7, p<0.001)
Margin dose <12 Gy (adjusted OR 0.25, p<0.05)
Multifocal disease (adjusted OR 4.38, p<0.001)
Distant failure 12.0% at 5 yrs
No significant change in LC or PFS with WHO Classification scheme
Surgical Considerations
- optic nerve sheath meningioma
- imaging-defined (asymptomatic tumor)
- inoperable (eg. cavernous sinus) location
- poor operative candidate
Radiation alone if:
Backer-Grondahl T, Moen BH, and Torp SH. The histopathological spectrum of human meningiomas. 2012. Int J Clin Exp Pathol. 5(3):231-242
Grade Varies by WHO Classification Scheme
Indications for intervention:
documented growth on serial imaging and/or
symptoms related to lesion uncontrolled with medical therapy

Superior sagittal sinus invasion
Complete occlusion -> do not resect sinus
Partial occlusion ->
anterior to coronal suture: sinus may usually be divided
posterior to coronal suture: may attempt to dissect tumor off sinus, or leave residual

Desse N, Malikov S, et al. Superior sagittal sinus reconstruction using a femoral venous graft after total removal of a meningioma. Case report. 2013. Neurochirurgie. 59(1): 43.46.
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