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

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

3. 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

4. Asdasd
2011 July October

5. Asdasd
2011 July October

6. 2011 October February June
3rd resection

7. 2012 June

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

9. 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

10. 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

11. Post-op course

12. 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

13. What does the future hold Mr. JD?

14. 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

15. Recurrence, Resection, Radiation

16. Recurrence, Resection, Radiation

17. Recurrence, Resection, Radiation

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

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

20. Recurrence, Resection, Radiation

21. 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

22. Creativity and the future

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