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 I HISTOLOGICAL SUBTYPE MENINGOTHELIAL, FIBROBLASTIC, TRANSITIONAL, ANGIOMATOUS, MICROCYSTIC, SECRETORY, LYMPHOPLASMACY TIC, PSAMMOMATOUS HISTOLOGIC FEATURES Does not fulfill criteria for grade II or grade III

II (ATYPICAL)

CHORDOID, CLEAR CELL

4 or more mitotic cells/ 10 hpf 3 or more of ff: -increased cellularity -small cells, necrosis -prominent nucleoli, sheeting -brain invasion in an otherwise Grade 1 tumor 20 or more mitosis/ 10 hpf Tumor cells resemble carcinoma, sarcoma or melanoma

III (ANAPLASTIC)

PAPILLARY, RHABDOID

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