Management of Meningiomas

DIAGNOSTIC TOOLS MRI –Dural tail, edema CT SCAN: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 GRADEHISTOLOGICAL SUBTYPE HISTOLOGIC FEATURES IMENINGOTHELIAL, FIBROBLASTIC, TRANSITIONAL, ANGIOMATOUS, MICROCYSTIC, SECRETORY, LYMPHOPLASMACY TIC, PSAMMOMATOUS Does not fulfill criteria for grade II or grade III

II (ATYPICAL)CHORDOID, CLEAR CELL4 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 III (ANAPLASTIC)PAPILLARY, RHABDOID20 or more mitosis/ 10 hpf Tumor cells resemble carcinoma, sarcoma or melanoma 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 – cGy –Daily fractions: cGy over 5-6 weeks –Particular care near optic nerves and brainstem Radiosurgery: Co- gamma unit –Dose delivered to margin of tumor : Gy –Proximal to optic nerves and chiasm: 9 Gy