meningioma, management of meningioma,

1. MENINGIOMA
DR SWARNITA SAHU
DNB RESIDENT
RADIATION ONCOLOGY
BATRA HOSPITAL, NEW DELHI

2. EPEDIMIOLOGY:
 Most common benign tumor of CNS.
 7th decade
 F : M – 2 : 1
 Refers to set of tumors that arise of meninges.
 May occur intracranially or within the spinal canal. They are thought to arise from
arachnoidal cap cells, which reside in the arachnoid layer covering the surface of brain.
 Intraventricular or intraosseous layer (rare).

3. RISK FACTORS
 LIKELY - first degree relative
NF2
ionizing radiation
 POSSIBLE - OCP
HRT
Obesity
Intrathecal Methotrexate.

4. Associated syndromes :
 Li Fraumeni Syndrome
 Turcots syndrome
 Gardeners
 Von Hippel Lindau
 Cowden
 Gorlin
 MEN I

5. PARASAGITTAL/FALCINE(25%)
Monoparesis of the contralateral leg
CONVEXITY (19%)
Depends on lobe involved

6. SPHENOID RIDGE (17%)
1) multiple cranial nerve palsies if superior orbital
fissures are involved.
SUPRASELLAR (9%)
1)Panhypopituitarism
2)Cavernous sinus: 2,3,4,5,6 CN palsy

7. POSTERIOR FOSSA (8%)
ataxia
respiratory abnormalites
cardiovascular abnormalities
nystagmus
imbalance
OLFACTORY GROOVE (8%)
FOSTER KENNEDY SYNDROME
Anosmia + I/L optic atropy + C/L papillaedema.

8. FORAMEN MAGNUM
Paraperesis
Sphincteric troubles
Tongue atrophy
SPINAL
Localised pain
Brown sequard syndrome

9. OPTIC NERVE SHEATH
mono-ocular vision loss
exopthalmos
CP ANGLE
Decreased hearing with possible facial
weakness & facial numbness

10. Plain radiograph
 no longer have a role in the diagnosis or
management.
 Historically a number of features were
observed, including:
I. enlarged meningeal artery grooves
II. hyperostosis or lytic regions
III. calcification
IV. displacement of calcified pineal
gland/choroid plexus due to mass effect

11. CT Scan:  First investigation for neurological signs
 Incidental finding
TYPICAL :
• Sharply circumscribed
Unilobular mass with a
broad based dural
attachment.
• They displace brain tissue
but does not invade it.
CALCIFICATION (20%-30%):
• Punctate /large or central/
peripheral.
• Slowly progressive benign
nature
• Malignant lesions are rarely
malignant.
HYPEROSTOSIS:
• Only if mass is
immediate
adjacent to the
bone.
• D/D - osteoma
pagets
Hyperostosis frontalis
LYTIC LESIONS :
• Associated with
hyperostosis.
• If purely lytic
lesion:
Myeloma
Metastasis
Sarcoma

12. MRI :
 unilobular masses with broad-
based dural attachments and
smooth, well-defined borders.
 On T1W and T2W images,
meningiomas are usually
isointense to normal gray
matter (in contrast with other
intracranial tumors).
 Nearly all meningiomas
enhance rapidly and intensely
following IV contrast
administration.

13. FEATURES OF EXTRA AXIAL MASS
• CSF CLEFT SIGN
• WHITE MATTER BUCKLING
• VESSELS PUSHED INSIDE
• BROAD BASE TOWARDS DURA

15. PSEUDOCAPSULE:
Represents the dura itself between the
tumor and the brain parenchyma.
DURA TAIL SIGN :
• not specific to meningioma.
• glioma
• brain metastasis
• acoustic neuroma
• lymphoma.

16. ATYPICAL IMAGING FEATURES:
PERITUMORAL OEDEMA
CYSTIC
LIPOBLASTIC
INTRACRANIAL HGE

17. MRS
• MR spectroscopy may provide additional information in differential diagnosis.
• The most common finding in meningiomas :
1. high Cho peak with low or absent NAA and Cr and variable amounts of lactate.
2. high ratio of Ala to Cr has been found in meningiomas (relatively specific finding).
• MR spectroscopy may differentiate histologically atypical meningiomas on the basis of
lactate peak at 1.3 ppm.

18. DSA (Digital subtraction angiography)
• Dual blood supply:
• PERIPHERY- Pial arteries (ICA)
• CORE – meningeal vessels (ECA)
• sunburst or spoke-wheel pattern .
• MOTHER IN LAW sign:
• tumor contrast blush "comes early, stays
late, and is very dense".
• rarely for diagnostic use
• rather as preoperative embolization to reduce
intraoperative blood loss .
• esp useful for skull base tumors, or those thought to be
particularly vascular .(e.g. microcystic variants or those
with very large vessels).
• 7-9 days prior to surgery.

19. HISTOLOGICAL GRADING:
(WHO)
I ) BENIGN (80-90%)
recurrence rates- 7 to 20 %
II) ATYPICAL/ CLEAR CELL / CHOROID( 5 -15%)
recurrence rate- 30-40 %
III) MALIGNANT ( ANAPLASTIC/RHABDOID/PAPILLARY)- (1-3%)
recurrence rate- 50-80%

20. MANAGEMENT:
treatment depends on meningioma size and location, and on patient age, symptoms, comorbidities, health status,
and treatment Preference
• observation : asymptomatic meningioma
• complete surgical resection : symptomatic meningioma
asymptomatic progressively enlarging tumors
• radiation therapy
inoperable or recurrent meningioma after surgery or radiation therapy
• medical therapies- may be tried but have limited and inconsistent evidence of efficacy

21. SURGERY:
grade Str removed Recurrence at 10 years
I Complete removal
Resection of underlying bone + associated dura
9 %
II Complete removal
Resection/coagulation of associated dura
19%
III Complete removal
Without resection/coag of dura
29%
IV SUBTOTAL RESECTION 44%
V DECOMPRESSION with or without biopsy 100%
SIMPSONS GRADING(1957)-

22. EMBOLIZATION:
• Preoperative embolization to minimize intraoperative bleeding.
• Alternative for nonsurgical canditates for craniotomy.
(reported marked tumor shrinkage over 20 months.)

23. RADIOTHERAPY:
• INDICATIONS:
• Primary treatment for inoperable.
• Patients with incomplete resection.
• Complete tumor eradication not possible but tumor shrinkage reported
• Tx to dose of 54 Gy for Grade I and 60 Gy for Grade II-III.
• TYPES:
 CONVENTIONAL RADIOTHERAPY.
 STEREOTACTIC RADIOTHERAPY.
Gamma knife
Cyber knife
 FRACTIONATED STEREOTACTIC RADIOSURGERY.
 INTENSITY MODULATED RADIATION THERAPY(IMRT).
 PROTON THERAPY

24. DOSE:
IMRT:
Gd I : 50 - 54 Gy
Gd II : 59.4 - 63 Gy
SRS:
Gd I : 12- 15 Gy
Gd II / III : 16-20 Gy
FSRT:
5-6Gy x 5
2.5Gy x 15

25. SRS
alternative to EBRT in patients with recurrent or partially resected meningiomas < 35 mm in diameter.
allows larger radiation doses to be delivered more accurately and limits radiation exposure to
surrounding tissue.
stereotactic radiosurgery reported the tumor control rates -
• 93% for Who Grade I tumors
• 50% for Who Grade II tumors
• 17% for Who Grade IIII tumors
Survival following stereotactic radiosurgery for benign meningioma appears
comparable to Simpson Grade I resection
as primary treatment for cavernous sinus meningiomas may be associated with better neurologic recovery
than surgical resection with adjuvant radiosurgery.
FRS: optic nerve sheath meningiomas
IMRT : irregularly shaped and too large for SRS.

26. Patient selection for SRS/FSRT:
SRS :
 <3 cm.
 Not directly abutting critical OARs.
 >3–5 mm from the optic apparatus (optic chiasm, optic nerves) to achieve adequate dose falloff
between the prescription dose and OAR tolerance (<8– 10 Gy for single-fraction SRS).
FSRT :
 (>3–4 cm),
 in closer proximity to or involving OARs
 • Optic nerve sheath and tuberculum sellae meningiomas are generally a contraindication for SRS in
patients with preserved vision given that the lowest therapeutic dose (12–13 Gy) exceeds optic apparatus
tolerance (8–10 Gy).

27. CONTOURING GUIDELINES:RTOG 0539
NEW GTR Gd II
RECURRENT Gd I
STR Gd II
RECURRENT Gd II
NEW / RECURRENT Gd III
DOSE 54Gy/30# 60 Gy/30#
GTV: tx bed on post op MRI
pre op MRI for confirmation
OEDEMA & DURAL TAIL- not included
CTV54-
GTV + 1 cm
margin to 0.5 cm arround natural barriers like skull.
If bone invasion + = margin reduction not done.
CTV 60- GTV+ 1cm
CTV 54- GTV+ 2cm (natural barrier reduced to 1cm)
If bone invasion present- no reduction
PTV : CTV + 3-5 mm
PRV : OAR + 3mm
OAR in close proximity to PTV, second PTV- PTVprv,dose is given close to 54Gy or 60 Gy at which the dose
constraints are attained.

28. MEDICAL:
Not standard
• For malignant meningiomas or as a last resort.
Types:
• Chemotherapy.
• hormonal therapy for unresectable or recurrent meningioma.
• somatostatin receptor agents.
• targeted molecular agents for recurrent or progressive meningioma.

29. CHEMOTHERAPY:
HYDROXYUREA:
median 2 months progression-free survival.
CYCLOPHOSPHAMIDE, ADRIAMYCIN, VINCRISTINE:
median survival 5.3 years

30. HORMONAL THERAPY:
Tamoxifen
Mifepristone
Temozolamide : median survival 7.5 months.
SOMATOSTATIN ANALOGUES:
Octreotide- median 4.2 months to progression
INTERFERON ALPHA:
Median survival – 8 months.
TARGETED THERAPY:
Imatinib: PFS 2 months
Geftinib/erlotinib: median overall survival 23 months.

31. PROGNOSIS :
median patient survival reported as:
• 10 years for WHO Grade I meningioma.
• 11.5 years for WHO Grade II meningioma.
• 2.7 years for WHO Grade III meningioma.
• 5 year survival rate:
• 81 % for age 21- 64 years
• 56 % for age >/= 65 years.
• POOR PROGNOSTIC MARKERS:
male
conformality index < 1.4
size > 10ml.

32. THANK YOU