Malignant Meningioma: rarity to creativity MGH Neurosurgery Grand Rounds August 23, 2012 Leonardo Aliaga University of Chicago

Complex history of multiple recurrent meningiomas JD, 53y/o RHM Complex history of multiple recurrent meningiomas 2008

2008 – initial resection at Umass Path – atypical meningioma (II) 2010 April – Proton beam therapy 2011 March – 2nd resection 4 meningiomas removed Radioactive iodine seeds placed Path – rhabdoid malignant meningioma (III) 2011 March, preop

Asdasd 2011 July 2011 October

Asdasd 2011 July 2011 October

2011 October 2012 February 2012 June 3rd resection

2012 June

August 2012, 4th resection Worsening left sided weakness Worsening eye pain, proptosis

August 2012, 4th resection Planned subtotal resection, sparing of eye Right frontal craniotomy - resection of 2 frontal parasagittal meningiomas Right orbitozygomatic osteotomy - resection of orbital sphenoid wing recurrence Planned subtotal resection, sparing of eye Exploration of infratemporal fossa

August 2012, 4th resection Planned subtotal resection, sparing of eye Right frontal craniotomy - resection of 2 frontal parasagittal meningiomas Right orbitozygomatic osteotomy - resection of orbital sphenoid wing recurrence Planned subtotal resection, sparing of eye Exploration of infratemporal fossa Plastic surgery – cranioplasty and scalp flap reconstruction

Post-op course

Post-op course Complicated by low hematocrit, tachycardia, confusion and delerium, downtrending Na Transfused, PE protocol CT negative, Na normalized Discharged on POD 8, LUE 3/5, LLE wiggled toes

What does the future hold Mr. JD?

Malignant Meningioma Meningiomas – 30% of CNS neoplasm Grade III – malignant meningioma, 1-3% 2007 WHO Criteria Papillary, rhabdoid and anaplastic histological subtypes 20 or more mitoses per HPF and/or malignant characteristics resembling carcinoma, sarcoma, or melanoma

Recurrence, Resection, Radiation

Recurrence, Resection, Radiation

Recurrence, Resection, Radiation

Recurrence, Resection, Radiation Marked survival benefit for 37 pts undergoing second resection for recurrence

Recurrence, Resection, Radiation 34 pts,undergoing primary operation 37 pts, undergoing second operation Minor survival benefit with subtotal resection vs. gross-total resection

Recurrence, Resection, Radiation

Recurrence, Resection, Radiation Radiation for recurrence 45 pts undergoing resection for recurrence 26 underwent at least 1 treatment of focal radiotherapy SRS Iodine-125 brachytherapy No difference in survival with focal radiotherapy after resection

Creativity and the future

Thank you MGH Department of Neurosurgery Harvard Medical School University of Chicago