Management Of Intracranial Meningiomas Research Articles

A Spotlight on the Role of Radiomics and Machine-Learning Applications in the Management of Intracranial Meningiomas: A New Perspective in Neuro-Oncology: A Review.

Background: In recent decades, the application of machine learning technologies to medical imaging has opened up new perspectives in neuro-oncology, in the so-called radiomics field. Radiomics offer new insight into glioma, aiding in clinical decision-making and patients’ prognosis evaluation. Although meningiomas represent the most common primary CNS tumor and the majority of them are benign and slow-growing tumors, a minor part of them show a more aggressive behavior with an increased proliferation rate and a tendency to recur. Therefore, their treatment may represent a challenge. Methods: According to PRISMA guidelines, a systematic literature review was performed. We included selected articles (meta-analysis, review, retrospective study, and case–control study) concerning the application of radiomics method in the preoperative diagnostic and prognostic algorithm, and planning for intracranial meningiomas. We also analyzed the contribution of radiomics in differentiating meningiomas from other CNS tumors with similar radiological features. Results: In the first research stage, 273 papers were identified. After a careful screening according to inclusion/exclusion criteria, 39 articles were included in this systematic review. Conclusions: Several preoperative features have been identified to increase preoperative intracranial meningioma assessment for guiding decision-making processes. The development of valid and reliable non-invasive diagnostic and prognostic modalities could have a significant clinical impact on meningioma treatment.

Stereotactic radiosurgery versus stereotactic radiotherapy in the management of intracranial meningiomas: a systematic review and meta-analysis.

OBJECTIVEStereotactic radiosurgery (SRS) and stereotactic radiotherapy (SRT) have been used as a primary treatment or adjuvant to resection in the management of intracranial meningiomas (ICMs). The aim of this analysis is to compare the safety and long-term efficacy of SRS and SRT in patients with primary or recurrent ICMs.METHODSA systematic review of the literature comparing SRT and SRS in the same study was conducted using PubMed, the Cochrane Library, Google Scholar, and EMBASE from January 1980 to December 2018. Randomized controlled trials, case-control studies, and cohort studies (prospective and retrospective) analyzing SRS versus SRT for the treatment of ICMs in adult patients (age > 16 years) were included. Pooled and subgroup analyses were based on the fixed-effect model.RESULTSA total of 1736 patients from 12 retrospective studies were included. The treatment modality used was: 1) SRS (n = 306), including Gamma Knife surgery (n = 36), linear accelerator (n = 261), and CyberKnife (n = 9); or 2) SRT (n = 1430), including hypofractionated SRT (hFSRT, n = 268) and full-fractionated SRT (FSRT, n = 1162). The median age of patients at the time of treatment was 59 years. The median follow-up duration after treatment was 35.5 months. The median tumor volumes at the time of treatment with SRS, hFSRT, and FSRT were 2.84 cm3, 5.45 cm3, and 12.75 cm3, respectively. The radiographic tumor control at last follow-up was significantly worse in patients who underwent SRS than SRT (odds ratio [OR] 0.47, 95% confidence interval [CI] 0.27-0.82, p = 0.007) with 7% less volume of tumor shrinkage (OR 0.93, 95% CI 0.61-1.40, p = 0.72). Compared to SRS, the radiographic tumor control was better achieved by FSRT (OR 0.46, 95% CI 0.26-0.80, p = 0.006) than by hFSRT (OR 0.81, 95% CI 0.21-3.17, p = 0.76). Moreover, SRS leads to a significantly higher risk of clinical neurological worsening during follow-up (OR 2.07, 95% CI 1.06-4.06, p = 0.03) and of immediate symptomatic edema (OR 4.58, 95% CI 1.67-12.56, p = 0.003) with respect to SRT. SRT could produce a better progression-free survival at 4-10 years compared to SRS, but this was not statistically significant (p = 0.29).CONCLUSIONSSRS and SRT are both safe options in the management of ICMs. However, SRT carries a better radiographic tumor control rate and a lower incidence of posttreatment symptomatic worsening and symptomatic edema, with respect to SRS. However, further prospective studies are still needed to validate these results.

Geographical Differences in Intracranial Meningioma Management: Examining 65,973 Patients across the United States.

Background Age, tumor size and location, overall health, and patient preference are primary considerations driving treatment decision-making for intracranial meningiomas. However, even for the same individual patient, treatment recommendations may vary between centers and providers. Objective To study associations between geography, disease presentation, and management of intracranial meningioma in the United States. Methods The population-based Surveillance, Epidemiology, and End Results(SEER) data were queried between 2004 and 2014 for cases of intracranial meningioma. Results A total of 65,808 patients with intracranial meningioma were identified. Univariate analyses demonstrated strong associations between geographic location, age, and size of tumor at presentation. The mean age for all registries was 64.2 years, with a range from 62.0 (Utah registry) to 66.6 (Detroit registry). The greatest proportion of small tumors (<1 cm) were identified in the Utah registry (13.9% of tumors), while the greatest proportion of large tumors (> 4cm) were noted in the Hawaii registry (30.7% of tumors). Multivariable analysis demonstrated that the impact of geography on treatment selection was just as important as other established variables. For example, the distribution in tumor size between New Mexico and Greater California registries is nearly identical; however, the odds ratio for surgery was 1.5 times greater for the New Mexico population. Conclusion These data suggest that disease presentation and treatment are significantly influenced by regional referral patterns, provider or institutional treatment preferences, and regional availability of subspecialty expertise. Understanding such biases is important for patients, referring physicians, and treatment providers in an effort to provide balanced counseling and treatment.

Racial Differences in Disease Presentation and Management of Intracranial Meningioma.

Objective/Hypothesis The aim of the study was to determine the impact of race on disease presentation and treatment of intracranial meningioma in the United States. Study Design This study comprised of the analysis of a national population-based tumor registry. Methods Analysis of the surveillance, epidemiology, and end results (SEER) database was performed, including all patients identified with a diagnosis of intracranial meningioma. Associations between race, disease presentation, treatment strategy, and overall survival were analyzed in a univariate and multivariable model. Results A total of 65,973 patients with intracranial meningiomas were identified. Of these, 45,251 (68.6%) claimed white, 7,796 (12%) black, 7,154 (11%) Hispanic, 4,902 (7%) Asian, and 870 (1%) patients reported "other-unspecified" or "other-unknown." The median annual incidence of disease was lowest among black (3.43 per 100,000 persons) and highest among white (9.52 per 100,000 persons) populations ( p < 0.001). Overall, Hispanic patients were diagnosed at the youngest age and white patients were diagnosed at the oldest age (mean of 59 vs. 66 years, respectively; p < 0.001). Compared with white populations, black, Hispanic, and Asian populations were more likely to present with larger tumors ( p < 0.001). After controlling for tumor size, age, and treatment center in a multivariable model, Hispanic patients were more likely to undergo surgery than white, black, and Asian populations. Black populations had the poorest disease specific and overall survival rates at 5 years following surgery compared with other groups. Conclusion Racial differences among patients with intracranial meningioma exist within the United States. Understanding these differences are of vital importance toward identifying potential differences in the biological basis of disease or alternatively inequalities in healthcare delivery or access Further studies are required to determine which factors drive differences in tumor size, age, annual disease incidence, and overall survival between races.

Hypofractionated Stereotactic Radiotherapy for Patients with Intracranial Meningiomas: impact of radiotherapy regimen on local control

We evaluated efficacy and tolerance of hypofractionated stereotactic radiation treatment (hFSRT) in the management of intracranial meningiomas. Between December 2008 and June 2016, 126 patients with 136 intracranial meningiomas were treated with robotic hFSRT. hFSRT was performed as primary irradiation and as a salvage option for the local recurrence after prior radiotherapy. The median prescription dose was 25 Gy (12–40) with a median number of fractions of 5 (3–10). After a median follow-up of 20.3 months (range 1–77 months), the 24-months local control (LC) rate was 81% in the primary hFSRT group and 39% after hFSRT in the re-irradiation group (p=0.002). The clinical control rate of symptoms in the overall population was 95% (95% CI: 89–98%). Progression-free survival (PFS) in the overall population at 24 months was 70% (95% CI: 60%–79%). In the primary hFSRT group, PFS was significantly lower with the most hypofractionated schedules of 21–23 Gy in 3 fractions vs. 25–40 Gy in 5–10 fractions: 62% vs. 92% (p = 0.0006). The incidence of radionecrosis at 24 months was significantly lower in the primary hFSRT group, at 2% vs. 20% in the re-irradiation hFSRT group (p = 0.002).

Racial Differences in Disease Presentation and Management of Intracranial Meningioma

Racial Differences in Disease Presentation and Management of Intracranial Meningioma

Management of Intracranial Meningioma

Objective: The aim of this study is to evaluate different modalities of treatment of intracranial meningioma which admitted to neurosurgery department of Sohag University through two years. Methods: we operated upon 30 patients with the oldest was 70 years old and the youngest was 16 years old, with mean age of 49.23 years 21 females and 9 males, according to the complaint the most common was headache in 20 cases, followed by fits in 12 cases, then weakness in 6 cases, and mental and behavioral changes in 5 cases, and vision changes in 4cases. Results: The lesion was totally removed in 24 cases and subtotal in 6 cases. Among these 30 patients 22 patients improved, 7 patients remained the same, and one patient deteriorated. Among the 30 patients two patient complicated by CSF leak and 4 patients complicated by wound infection, and only two patients showed increased weakness, As for the pathology 7 cases with transitional meningiomas, 4 cases fibroblastic meningiomas, 2 cases with atypical meningiomas, 9 cases meningiothelial meningiomas, 5 cases psammomatus meningiomas, 3 cases mixed meningiomas. Conclusion: The use of both computerized tomography and magnetic resonance imaging was found to be mandatory and none of them can replace the other for proper and accurate diagnosis and visualization of these meningiomas preoperatively. The choice of surgical approach remains that of surgeon guided by tumor nature and many other factors. Although these approaches were found to be extremely satisfactory when properly selected, every effort should be done for applying the minimally invasive approaches as well as key-hole surgery whenever appropriately indicated and with the availability of their modern technical instrumentations and adjunctive image guidance.

Trends in Management of Intracranial Meningiomas: Analysis of 49,921 Cases from Modern Cohort.

We sought to characterize patterns and treatment for intracranial meningiomas in the Surveillance, Epidemiology, and End Results set of cancer registries. SEER data was queried from 2004-2012 for cases of intracranial meningioma using appropriate topography and histology codes. A total of 49,921 patients with intracranial meningioma were identified. The vast majority of cases were associated with a benign histology (n= 47,047, 94.2%). There were 21,145 patients (42.4%) who underwent surgical management, 2783 who received radiation alone (5.6%), and 25,993 who underwent surveillance only (52.1%). Surgical management decreased in frequency from 48.8% of all cases in 2004 to 38.3% of cases in 2012 (P < 0.001). Radiation alone remained stable over time with a range of 4.8%-6.3% of cases. Observation increased from 45.0% of cases in 2004 to 56.7% of cases in 2012 (P < 0.001). On unadjusted analysis, surgical management was associated with younger age and larger tumor size. The incidence of tumors <2 cm in size increased significantly over the study period from 29.7% in 2004 to 41.7% in 2012 (P < 0.001). After adjusting for tumor size, multivariable analysis demonstrated that the odds of observation as a primary management strategy were greater in 2012 relative to 2004 (odds ratio 1.33, 95% confidence interval 1.21-1.45). The incidence of intracranial meningiomas increased, while tumor size at the time of diagnosis decreased. Moreover, the number undergoing no treatment increased as a treatment strategy and was more likely employed for older patients, those of African-American race, and those with smaller tumors.

The Role of Radiotherapy in the Management of Intracranial Meningiomas

INTRODUCTION: Cerebral meningiomas account for 15–20% of all cerebral tumors. Although seldom malignant, they frequently recur in spite of complete surgery, which remains the cornerstone of the treatment. In order to decrease the probability of local recurrence, radiotherapy has often been recommended in atypical or malignant meningioma as well as in benign meningioma which was incompletely resected. However, this treatment never was the subject of prospective studies, randomized or not. METHODS: We retrospectively reviewed all patients with meningioma treated with radiotherapy in the oncology department of Hospital University Mohammed 6 in Marrakech from 1 January 2011 to 1 December 2014. Demographic data including age, sex, and clinical signs revealing meningioma Been studied. All patients in the study received surgical treatment and radiotherapy. The histological data of the surgical specimens have been studied, neurological evolution and therapeutic complications were analyzed. RESULTS : From January 2011 to December 2014, six patients were identified with a median age of 43.5 years (range 25-56years). Sex-ratio was 0.5. Headache was the most common presenting symptom manifesting in 4 patients (66,6 %). Tumors were mostly located in the convexity (83.3%). Five patients underwent complete excision (Simpson I A III) and 1 underwent subtotal excision (Simpson IV). On histopathological analysis, 2 patients (33,3%) had WHO grade I, 2 patients (33,3%) had WHO grade II (atypical) and 2 patients (33,3%) grade III. 4 patients had adjuvant radiation from initial management and 2 patients with grade I meningioma had adjuvant radiotherapy after recurrence and surgical reoperation. For evolution, a tumor recurrence was observed at control imaging in the 12th months, the disease was stabilized for the patient with sphenoorbital localization, for the remaining four patients, the disease was controlled. No grade 3 or 4 toxicity were observed. ca—a½“ao•c«¯ CONCLUSION: Adjuvant radiotherapy improved local control after incomplete resection for grade I meningiomas, and after complete resection for high-grade meningiomas.

Surgical Management of Meningiomas 6 Months Fellow Up of 85 Cases in a Sub-Saharian Countrie

Objective: To evaluate the surgical management of intracranial meningiomas and the 6 months postoperative course. Method: Prospective study was conducted between January 2002 and May 2012. Were included patients for whom surgical resection of meningioma was made ??and whose follow-up was at least 6 months. The quality of resection was evaluated according to the criteria of Simpson. Karnofsky index was used to assess the pre-and postoperative morbidity. Results: 85 cases of intracranial meningiomas were included. The sex ratio was 0.88/1. The average age was 54.41 years. The mean disease duration was 7.17 months. It was supra tentorial meningiomas in 70.57% of cases, infra-tentorial meningiomas for 11.76% of cases and skull base meningiomas for 17.64% of cases. Karnofski average score at admission was 48.53 with 57% of patients with a score between 10 and 40. 95.29% of patients were operated according to Simpson I, II and 4.710 / 0 according to Simpson IV. It was benign meningiomas in 97.65% of cases. At 6 months theKarnofskipostoperative average score was 83.7. The postoperative mortality was 1.17%. Conclusion: The surgical treatment of meningiomas improves the clinical status of patients with low morbidity and mortality.

髄膜腫治療のエビデンス

髄膜腫治療のエビデンス

Clinical course and management of intracranial meningiomas in neurofibromatosis type 2 patients

ObjectiveThe aim of this study is to evaluate our surgical experience with intracranial meningiomas in NF2 patients and provide knowledge of the natural history of these lesions. MethodsWe included in the natural growth study patients with the diagnosis of NF2 who harbored intracranial meningiomas and were observed for at least 1 year. Tumors that were resected before achieving long-term follow-up were excluded from this analysis. ResultsWe found 118 intracranial meningiomas in 34 patients in our series. 8 meningiomas in 7 patients were symptomatic. It was found that with an increase in tumor volume, brain edema and with the tumor location at the skull base, meningiomas are more likely to be symptomatic. Univariate analysis revealed that tumor growth was associated with a younger age at the onset of NF2-related symptoms, greater initial tumor volume, brain edema and with the presence of intracranial non-vestibular schwannoma. Multivariate analysis showed that the probability of tumor growth is associated with prolonged follow-up time. De novo meningiomas exhibited a significantly higher growth rate than other meningiomas. These tumors were more frequent in patients with intracranial non-vestibular schwannoma and with increasing length of meningioma observation. ConclusionMeningiomas occur in about half NF2 patients. Many of them exhibit slow growth and long remain asymptomatic, however, those associated with early onset of NF2 symptoms and other features of the disease severity should be monitored in case of clinical and radiological progression that may require surgical treatment.

MRI Pre- and Post-Embolization Enhancement Patterns Predict Surgical Outcomes in Intracranial Meningiomas.

To evaluate the effects of preoperative embolization on overall surgical outcomes after meningioma resection and determine whether pre- and postembolization tumor enhancement patterns on magnetic resonance imaging (MRI) scans can be used to assess the efficacy of embolization. We developed a prospective database of all patients who underwent surgical resection with or without preoperative embolization for extra-axial intracranial meningiomas from 2004 to 2010. Using specialized computer software, the total volume of enhancement was calculated in pre- and postembolization MRI scans to quantify the percentage of embolization, which was described as the embolization fraction (EF). A total of 89 patients underwent surgical resection. Fifty two patients underwent embolization prior to surgery. Tumor location significantly correlated with the decision to embolize preoperatively. Adequate embolization was achieved in 58% of patients. Forty four patients (84.6%) had a postsurgical Karnofsky performance score (KPS) of 80 or above, while 46 patients (88.4%) had a postsurgical Glascow Outcome Score (GOS) of 4 or 5. The mean EF was 25.03% with a median of 18.72%. A greater extent of embolization as quantified by EF led to decreased intraoperative blood loss (r = -.319, P = .022) and better postsurgical outcomes as defined by KPS (r = .279, P = .044). Pre- and postembolization tumor enhancement patterns on magnetic resonance imaging defined as EF correlate with improved surgical facilitation and postoperative functional outcomes in the management of intracranial meningioma.

The role of preoperative embolization for intracranial meningiomas

As endovascular techniques have become more advanced, preoperative embolization has become an increasingly used intervention in the management of meningiomas. To date, however, no consensus has been reached on the use of this technique. To clarify the role of preoperative embolization in the management of meningiomas, the authors conducted a systematic review of case reports, case series, and prospective studies to increase the current understanding of the management options for these common lesions and complications associated with preoperative embolization. A PubMed search was performed to include all relevant studies in which the management of intracranial meningiomas with preoperative embolization was reported. Immediate complications of embolization were reported as major (sustained) or minor (transient) deficits, death, or no neurological deficits. A total of 36 studies comprising 459 patients were included in the review. Among patients receiving preoperative embolization for meningiomas, 4.6% (n = 21) sustained complications as a direct result of embolization. Of the 21 patients with embolization-induced complications, the incidence of major complications was 4.8% (n = 1) and the mortality rate was 9.5% (n = 2). Preoperative embolization is associated with an added risk for morbidity and mortality. Preoperative embolization may be associated with significant complications, but careful selection of ideal cases for embolization may help reduce any added morbidity with this procedure. Although not analyzed in the authors' study, embolization may still reduce rates of surgical morbidity and mortality and therefore may still have a potential benefit for selected patients. Future prospective studies involving the use of preoperative embolization in certain cases of meningiomas may further elucidate its potential benefit and risks.

Management of intracranial meningiomas in Enugu, Nigeria

Background:Meningiomas may range on presentation from incidentally identified small lesions to large symptomatic tumors in eloquent areas of the brain. Management options correspondingly vary and include careful observation, surgical excision, and palliative application of very limited therapeutic maneuvers in select cases. This paper discusses the options and difficulties in the management of meningiomas in a developing country.Methods:This study is a retrospective analysis of prospectively recorded data of patients managed for intracranial meningioma between January 2006 and September 2011 at Memfys Hospital for Neurosurgery, Enugu. Radiographic diagnosis of meningioma was based on computed tomography (CT) and or magnetic resonance imaging (MRI) criteria in all cases, but only patients who had surgery and a histological diagnosis were analyzed.Results:Seventy-four patients were radiographically diagnosed with intracranial meningioma over the period under review. Fifty-five patients were operated upon and 52 (70.3%) with histological diagnosis of meningioma were further analyzed. Histological diagnosis was complete in 42 (56.8%) patients and in 10 (13.5%) patients the subtype of meningioma was not determined. The male to female ratio was 1:1.08. The peak age range for females was in the 6th decade and for males in the 5th decade. The locations were olfactory groove (26.9%), convexity (21.2%), parasagittal/falx (19.2%), sphenoid ridge (15.4%), tuberculum sellae (7.7%), tentorial (3.8%), and posterior fossa (5.8%). The most common clinical presentation was headaches in 67.3% followed by seizures (40.4%) and visual impairment (38.5%). Histology was benign (World Health Organization [WHO] grade 1) in 39 patients. One patient harbored an atypical and two had anaplastic tumors. Gross total resection of the tumor was achieved in 41 patients. Surgical mortality was 3.9%.Conclusion:Effective management of meningioma depends largely on adequate and complete surgical resection and results in good outcomes. Adequate preoperative assessment, including visual assessment, and hormonal assessment in olfactory groove and sphenoid region meningiomas, is necessary.

Editorial: Meningioma surgery

Over the past 20 years, the management of intracranial meningiomas has changed. Surgical removal remains the gold standard to which alternative therapies are compared. However, advanced radiation oncology techniques, such as stereotactic radiosurgery and intensity-modulated radiotherapy, have increasingly been applied in the treatment of smalland medium-sized tumors as well as incompletely resected lesions.1,2 Furthermore, as Sughrue et al.4 mention, conservative management of asymptomatic meningiomas is an increasingly viable option for some patients. The overall result is that the population that undergoes microsurgical removal of meningiomas are, on average, older, more likely to have neurological symptoms, and more likely to harbor larger lesions, as compared with patients 20 years ago.3 These characteristics underscore the need for neurosurgeons to be able to accurately assess risks associated with microsurgical resection. The following study by Sughrue et al.4 features a large series of patients and evaluates the rate and types of medical complications in those who have undergone microsurgical removal of meningiomas. The authors included all craniotomies for meningiomas during a 15year period, numbering 834 cases. Overall, the findings are not unexpected, but they do provide valuable insights into the specific risk factors and variables that may lead to postoperative medical complications. The rate of serious medical complications in these patients was low (6.8%), which, in the authors’ estimation, reflects the indolent nature of the disease and the careful selection of surgical candidates. Given the low rate of medical complications in these patients, large studies such as this are necessary to accurately investigate rates of medical and neurological complications. Statistically significant predictors of postoperative medical complications in this study, such as an age > 65 years, hypertension, and 2 or more cardiac medications, are not unexpected. However, it is interesting to note that the strongest predictor of a serious medical complication was a new or worsened postoperative neurological deficit. The explanation offered by the authors that seems most plausible is that in many cases the new neurological deficit (for example, weakness in 1 or more extremities) predisposed a patient to a medical complication (for example, deep vein thrombosis and pulmonary embolus). Given the efficacy of radiosurgery for residual tumor, these data and observations perhaps underscore the notion of conservative resection with postoperative observation or radiation, especially for tumors in locations more difficult to access such as the foramen magnum and petroclival region. In other words, tailoring the goals of resection to minimize neurological complications may help to minimize the risk of serious medical complications. Patients expect and deserve their neurosurgeons to be fully aware of all risks associated with their surgery and to anticipate and intervene appropriately when complications arise. Much of the literature regarding complications from meningioma surgery is devoted to surgical and neurological complications. The authors of this study are to be commended not only for reinforcing the need to be mindful of serious medical complications, but also for observing the association between postoperative neurological and medical complications. Understanding the rates and risk factors for both types of complications can only help to reduce the incidence of potentially devastating outcomes.

Fractionated radiotherapy for intracranial meningiomas

Fractionated external beam radiotherapy (EBRT) has multiple roles in the management of intracranial meningiomas. In multiple series post-operative EBRT has shown improved progression-free survival following subtotal resection and a reduction in long-term failures following an apparent gross total resection. In the definitive setting, the use of EBRT has increased as the growing utilization of neuro-imaging for various conditions identifies skull-based lesions which are not easily resectable. Optic nerve sheath meningiomas represent a classic example of the use of definitive EBRT, given the frequent visual sequelae of surgery or observation. EBRT planning is highly individualized and requires a detailed understanding of tumor grade, adjacent radiosensitive structures such as the anterior optic apparatus, and radiographic characteristics of the tumor such as hyperostosis.

Nonsurgical treatment options in the management of intracranial meningiomas

Surgical resection is the treatment of choice for most intracranial meningiomas. We review the current state of adjuvant therapies, including radiation and chemotherapy. Conventional external beam radiation and stereotactic radiosurgery remain second-line options for patients unwilling or unable to undergo surgery. Radiation therapy is most useful in the setting of recurrent or residual tumor after surgical resection, where it is associated with a clear increase in the length of progression-free survival. This survival advantage is most pronounced with high-grade meningiomas, which have a much higher recurrence rate than low-grade meningiomas, even after gross total resection. In contrast, the role of chemotherapy in the treatment of meningiomas is limited. This treatment modality is often reserved for inoperable tumors or those refractory to radiation treatment. Furthermore, the choice of chemotherapy agents is limited. Hydroxyurea, a ribonucleotide reductase inhibitor, has modest clinical activity in meningiomas. In recent small clinical trials, somatostatin analogues have been moderately effective in controlling tumor growth.

Radiotherapy as an adjuvant in the management of intracranial meningiomas: are we practising evidence-based medicine?

Although increasingly used, the precise role of radiotherapy in the management of meningiomas is still disputed. The objective of this study, therefore, was to appraise the evidence for adjuvant radiotherapy in benign and atypical intracranial meningiomas, and to compare and contrast it with the current opinion and practice of neurosurgeons in the United Kingdom and the Republic of Ireland. The use of radiotherapy as a primary treatment strategy or its use in the treatment of recurrence was not considered. We performed a systematic review of the evidence for adjuvant radiotherapy in benign and atypical intracranial meningiomas, surveyed current opinion amongst neurosurgeons involved in such cases and ascertained local practice using data from the regional cancer registry. Overall, 10 cohorts were identified that fulfilled our eligibility criteria. Four studies showed significantly improved local control in patients receiving adjuvant radiotherapy for incompletely resected grade I meningiomas. Our survey demonstrated that the vast majority (98%) of neurosurgeons would not recommend adjuvant radiotherapy in grade I meningioma. In grade II meningioma, most (80%) would not advocate adjuvant radiotherapy if completely excised, but the majority (59%) would recommend radiotherapy in cases of subtotal resection. Significant variation in opinion between centres exists, however, particularly in cases of completely resected atypical meningiomas (p = 0.02). Data from the Eastern Cancer Registration and Information Centre appears to be in line with these findings: less than 10% of patients with grade I meningiomas, but almost 30% of patients with grade II meningiomas received adjuvant radiotherapy in the Eastern region. In conclusion, our study has highlighted significant variation in opinion and practice, reflecting a lack of class 1 evidence to support the use of adjuvant radiotherapy in the treatment of meningiomas. Efforts are underway to address this with a randomized multicentre trial comparing a policy of watchful waiting versus adjuvant irradiation.

Problems in the Management of Intracranial Meningiomas

Meningiomas account for approximately 15–20% of all brain tumors, and are the most common benign intracranial tumor. These neoplasms develop from cap cells in the arachnoidea; thus, they can be found anywhere that dura mater exists. Meningiomas are usually diagnosed in middle age, and are significantly more frequent in females than in males. Atypical and anaplastic malignant forms also exist. Some types of meningiomas are difficult to manage and require special considerations. The first-line therapy for meningioma is surgery aimed at total excision; however, limitations of surgery must be fully evaluated in order to achieve better results. Conventional radiotherapy and gamma-knife radiosurgery can be used as adjuvant therapeutic modalities under certain conditions. The issues that we consider important in the management of intracranial meningiomas can be discussed under the headings of diagnosis, surgery, multiplicity, pathology, and recurrence.