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Adjuvant Treatment in Meningioma
1. Adjuvant treatment in meningioma
Debnarayan Dutta, MD
Consultant Radiation Oncologist
Apollo Speciality Cancer Hospital, Chennai
2. CBTRUS 2015
•Meningiomas account for ᷉35 % of all primary
intracranial tumors .
• Mostly slow growing
Histological types:
- Grade I ᷉90 %.
- Atypical 5-7%
- Malignant 1-3 %
Meningioma: Facts
• 90% of the meningiomas are grade I
• Suually complete surgical resection is done
• No Adj RT required
• Excellent long-term control
3. Meningioma: Gr-I
Meningioma Gr-I:
- Usually GTR done
- <5% recurrence after GTR
- Residual tumour / progression – adj RT
Usually Gr I meningiomas are observed in total or
subtotal resection done
Even in small (<1.5 cm) residual disease observation
Outcome is 80-90% LC at 10 yrs
Residual disease, 3 monthly MRI scan
Role of Adj RT only if there is progression on follow up scan
Surgery not possible
4. Meningioma: Gr-I
- Optic Nr sheath meningioma Parasagittal meningioma involving veins
• No randomized study
• No randomized study on radiation dose or fractionation
• Usually treated with 50.4Gy/28# SCRT OR 25Gy/5# fSRS or 13Gy/1# SRS
• ‘Lack of progression’ after RT is considered response
5. Meningioma: Facts
• Atypical meningiomas: therapeutic challenge
given their high recurrence rates.
• Gross total resection is done , RT reserved for
residual disease or recurrences.
• Optimal Rx of AM still controversial
Tumor recurrence rate
GTR Only- 41%
GTR and post-op EBRT - 11.8%.
6. Author Local Recurrence
Mirimanoff (MGH)
Condra (U Fl)
Stafford (Mayo)
5-yr
7%
7%
12%
10-yr
20%
20%
25%
15-yr
32%
24%
-
Gross Total Resection: High Late Relapse
May sometimes cause significant morbidity in certain sites
7. Author Local Recurrence
Wara (UCSF)
Condra (U Fl)
Stafford (Mayo)
5-yr
47%
47%
39%
10-yr
63%
60%
61%
15-yr
-
70%
-
20-yr
75%
-
-
Subtotal Resection
Challenge is to report on all consecutive patients
11. Meningioma G2: Sum ups
RT has improved PFS/ OS
RT marginally improved PFS
RT worse PFS
12. Klinger DR, World Neurosurgery, 2015
Atypical Meningioma: Factors influencing outcome
MIB Index (ki67) Mitotic Index
Region of lesion
Factors:
1. MIB Index
2. Mitotic Index
3. Resection
4. Region of lesion
5. Molecular typing
14. Indian data
• The median dose of EBRT was 59.4 Gy (50.4Gy- 60 Gy)
• Median time to follow-up was 4.5 years (4 months–8 years)
• 41.5% (22) patients had recurrence after surgery.
• 14.5% (7 of 48 patients) who received radiotherapy developed post-RT recurrence with a
median time of 36 months (range 12 – 60 months).
• 50 patients at the time of their last follow-up had KPS of >=80% and 5 patient expired.
OSPFS
3 yrs – 91%3 yrs – 85%
Jalali R, Submitted
16. Response to treatment assessment
• ‘Lack of progression’ after conventional RT is considered response
• Increase in size as per RECIST criteria in considered progression
• High dose per fraction induce early regression in meningioma
• SRS (CyberKnife) induce early response with volume reduction
Pre-RT Post-RT: 6 mo
- No significant change in size of mass: stable disease
18. Analastic meningioma
- Normal brain invasion criteria for anaplastic meningioma
- Usually subtotal resection
- Irrespective of total or subtotal resection: Adj RT required
- No Randomized study
- CTV margin: 2-3 cm, PTV margin: 0.5 cm
- RT dose: 60 Gy/30#
- Outcome dismal, 60-70% recurrence at 2 yr
19. RT planning: meningioma
GTV/CTV = residual tumour / tumour bed for gr II / gr III
CTV = 5 mm for benign meningiomas
2 - 3 cms for high grade meningiomas / HPC
PTV = 2mm for SRT
5mm for 3DCRT
All normal structures contoured
Dosage:
Gr-I:
54Gy/30# conformal RT
25Gy/5# / 13Gy/1#
Gr II & III meningioma:
60Gy/30#/6wks
Conformal RT
Grade I Grade II/III
Tharmoplastic mask
CT scan with contrast- 3 mm slice
MRI scan with T1 contrast & T2 flair is a must
20. Goldsmith J Neurosurg 80:195-201, 1994
0 60 120 180 240
Months
0.0
0.2
0.4
0.6
0.8
1.0
98%: RT with CT/MR (n=77)
77%: RT without CT/MR (n=40)
Progression-Free Survival
STR + postop RT; p=0.002
Impact of modern RT planning
46. Robotic Radiosurgery
Highly precise RT delivery system
- Respiratory tracking
- Fiducial based tracking system
- Intra-fraction motion correction
- Uncomparable dose distribution
- X-ray based image verification
Hypofractionated RT
- High dose short course RT
- Higher BED delivered to target
53. ConclusionsGr I meningiomas:
Majority of the meningiomas are slow growing, Gr I
Usually complete resection possible
NO Adj RT required in majority, ONLY observation
Adj RT in progressive disease, where surgery not possible
Gr 2 meningiomas:
Role of adj RT is controversial
Pts with high MIB index, mitotic index, partial resection need adjuvant RT
Pts with TERT mutation are aggressive, high recurrence rate & need RT
Gr 3 Meningiomas:
Aggressive disease
High local recurrence
Need always adjuvant RT
Standard treatment:
Gr I: No consensus, No study between Conventional RT or SRS
Small vol disease, SRS (CyberKnife) is an option
Gr II & III: Conventional fractionation (54-60Gy)
