WHO grade, proliferation index, and progesterone receptor expression are different according to the location of meningioma

Single versus multiple reoperations for recurrent intracranial meningiomas

PURPOSE

To identify the risk factors and management of the multiple recurrences and reoperations for intracranial meningiomas.

METHODS

Data of a neurosurgical series of 35 patients reoperated on for recurrent intracranial meningiomas were reviewed. Analyzed factors include patient age and sex, tumor location, extent of resection, WHO grade, Ki67-MIB1 and PR expression at initial diagnosis, time to recurrence; pattern of regrowth, extent of resection, WHO grade and Ki67-MIB1 at first recurrence were also analyzed. All these factors were stratified into two groups based on single (Group A) and multiple reoperations (Group B).

RESULTS

Twenty-four patients (69%) belonged to group A and 11 (31%) to group B. The age < 65 years, male sex, incomplete resection at both initial surgery and first reoperation, and multicentric-diffuse pattern of regrowth at first recurrence are risk factors for multiple recurrences and reoperations. In group B, the WHO grade and Ki67-MIB1 increased in further recurrences in 54% and 64%, respectively. The time to recurrence was short in 7 cases (64%), whereas 4 patients (36%) further recurred after many years. Eight patients (73%) are still alive after 7 to 22 years and 2 to 4 reoperations.

CONCLUSION

The extent of resection and the multicentric-diffuse pattern of regrowth at first recurrence are the main risk factors for multiple recurrences and reoperations. Repeated reoperations might be considered even in patients with extensive recurrent tumors before the anaplastic transformation occurs. In such cases, even partial tumor resections followed by radiation therapy may allow long survival in good clinical conditions.

Topographic Patterns of Intracranial Meningioma Recurrences-Systematic Review with Clinical Implication

BACKGROUND

While several risk factors for recurrences have been defined, the topographic pattern of meningioma recurrences after surgical resection has been scarcely investigated. The possibility of theoretically predicting the site of recurrence not only allows us to better understand the pathogenetic bases of the disease and consequently to drive the development of new targeted therapies, but also guides the decision-making process for treatment strategies and tailored follow-ups to decrease/prevent recurrence.

METHODS

The authors performed a comprehensive and detailed systematic literature review of the EMBASE and MEDLINE electronic online databases regarding the topographic pattern of recurrence after surgical treatment for intracranial meningiomas. Demographics and histopathological, neuroradiological and treatment data, pertinent to the topography of recurrences, as well as time to recurrences, were extracted and analyzed.

RESULTS

Four studies, including 164 cases of recurrences according to the inclusion criteria, were identified. All studies consider the possibility of recurrence at the previous dural site; three out of four, which are the most recent, consider 1 cm outside the previous dural margin to be the main limit to distinguish recurrences closer to the previous site from those more distant. Recurrences mainly occur within or close to the surgical bed; higher values of proliferation index are associated with recurrences close to the original site rather than within it.

CONCLUSIONS

Further studies, including genomic characterization of different patterns of recurrence, will better clarify the main features affecting the topography of recurrences. A comparison between topographic classifications of intracranial meningioma recurrences after surgery and after radiation treatment could provide further interesting information.

A comprehensive correlation of the KI-67 proliferation index to patient´s, imaging and tumor features and its value in predicting long-term course of patients with newly diagnosed intracranial meningiomas

To analyze the correlation of KI-67-Proliferation Index (KI-67-PI) with preoperative patients and MRI characteristics, WHO grading, histological subtype and long-term-course of patients with newly diagnosed intracranial meningiomas (IM). In this single-center retrospective study, all consecutive patients with IM were analyzed from January 2007 to August 2019. Patient´s demographics (age, sex), imaging parameters (location, volume, edema, necrosis), and tumor features (WHO grade, histology) were assessed and correlated with KI-67-PI. Long-term data were retrieved from patient's last follow-up visits. This study included 463 IM in 457 surgically treated patients. Males exhibited a higher KI-67-PI than females (7.31 ± 0.22 vs. 5.37 ± 0.53; p < 0.01, Mann-Whitney U Test). Age positively correlated with KI-67-PI in both sexes (p < 0.01, Spearman), with older patients having a higher KI-67-PI. KI-67-PI was significantly higher in convexity IM compared to frontobasal IM (7.15 ± 5.56 vs. 4.66 ± 2.94; p < 0.05, ANOVA, Tukey´s HSD), while no difference in KI-67-PI expression was found when other locations were compared to each other (Tukey´s HSD). Higher KI-67-PI was significantly correlated with larger tumor volume (p < 0.01, Spearman), larger tumor necrosis and larger peritumoral edema (p < 0.01, Kruskal-Wallis). Patients with recurrent IM had a significantly higher KI-67-PI than patients without recurrence (8.24 ± 5.88 vs. 5.14 ± 3.53; p < 0.01, ANOVA, Tukey´s HSD) during a mean follow-up period of 80.92 ± 38.1 months. Atypical and anaplastic IM exhibited significantly higher KI-67-PI compared to all other WHO grade 1 histological subtypes (12.09 ± 0.73 vs. 4.51 ± 0.13; p < 0.01, Kruskal-Wallis test) and KI-67-PI was significantly higher in anaplastic IM compared to atypical meningioma (19.67 ± 1.41 vs. 11.01 ± 0.38; p < 0.01, ANOVA). Higher KI-67-PI is not only associated with atypical and anaplastic subtypes of IM, but is also significantly higher in males, positively correlates with patients age, larger tumor volume, lager peritumoral edema and necrosis on preoperative MRI and predicts tumor recurrence. Therefore, KI-67-PI may serve as a decision indicator for adjuvant treatment in patients with IM.

Meningioma recurrence: Time for an online prediction tool?

Background

Meningioma, the most common brain tumor, traditionally considered benign, has a relatively high risk of recurrence over a patient's lifespan. In addition, with the emergence of several clinical, radiological, and molecular variables, it is becoming evident that existing grading criteria, including Simpson's and World Health Organization classification, may not be sufficient or accurate. As web-based tools for widespread accessibility and usage become commonplace, such as those for gene identification or other cancers, it is timely for meningioma care to take advantage of evolving new markers to help advance patient care.

Methods

A scoping review of the meningioma literature was undertaken using the MEDLINE and Embase databases. We reviewed original studies and review articles from September 2022 to December 2023 that provided the most updated information on the demographic, clinical, radiographic, histopathological, molecular genetics, and management of meningiomas in the adult population.

Results

Our scoping review reveals a large body of meningioma literature that has evaluated the determinants for recurrence and aggressive tumor biology, including older age, female sex, genetic abnormalities such as telomerase reverse transcriptase promoter mutation, CDKN2A deletion, subtotal resection, and higher grade. Despite a large body of evidence on meningiomas, however, we noted a lack of tools to aid the clinician in decision-making. We identified the need for an online, self-updating, and machine-learning-based dynamic model that can incorporate demographic, clinical, radiographic, histopathological, and genetic variables to predict the recurrence risk of meningiomas.

Conclusion

Although a challenging endeavor, a recurrence prediction tool for meningioma would provide critical information for the meningioma patient and the clinician making decisions on long-term surveillance and management of meningiomas.

Time to Recurrence of Intracranial Meningiomas from a Monoinstitutional Surgical Series

BACKGROUND

Meningiomas show variable tendency to recur. While risk factors of recurrence have been largely investigated in literature, a paucity of data is available on the time to recurrence. Our purpose was to identify main factors affecting the time to recurrence to assist preoperative treatment decision-making strategy and to define a tailored clinical and neuroradiological follow-up.

METHODS

Data of 35 patients with intracranial meningioma recurrences have been retrospectively reviewed. Demographic (patient age at initial diagnosis and sex), radiologic (meningioma location, pattern of regrowth and topography of recurrences at first reoperation), pathologic (WHO grade and Ki67-MIB1 at initial surgery and at first reoperation, progesterone receptor [PR] expression), and surgical (extent of resection at initial surgery according to Simpsons grading system, number of reoperations) factors were analyzed.

RESULTS

Time to recurrence ranged from 20 to 120 months. Extent of resection at initial surgery was Simpson grade I in 7 patients (20%), grade II in 10 (28.5%), grade III in 14 (40%), and grade IV in 4 (11.5%). Longer median time to recurrence was observed for skull base localization (P < 0.01), Simpson grades I and II versus grades III (P = 0.01) and IV (P = 0.02), values of Ki67-MIB1 ≤ 4% (P = 0.001), and PR > 60% (P = 0.03); conversely, sex, age, number of reoperations, unchanged/progression of Ki67, and/or World Health Organization grade between first surgery and reoperation did not correlate in statistically significant way with time to recurrence.

CONCLUSIONS

The extent of resection and the Ki67-MIB1 represent the most important factors predicting shorter recurrence time of intracranial meningiomas. Patients with incomplete (Simpson grades III and IV) resection and high Ki67-MIB1 values, especially at non-skull base localization and with low PR values, require a closer short-term clinical and radiologic follow-up in the first years after surgery.

Use of progestogens and the risk of intracranial meningioma: national case-control study

OBJECTIVE

To assess the risk of intracranial meningioma associated with the use of selected progestogens.

DESIGN

National case-control study.

SETTING

French National Health Data System (ie, Système National des Données de Santé).

PARTICIPANTS

Of 108 366 women overall, 18 061 women living in France who had intracranial surgery for meningioma between 1 January 2009 and 31 December 2018 (restricted inclusion periods for intrauterine systems) were deemed to be in the case group. Each case was matched to five controls for year of birth and area of residence (90 305 controls).

MAIN OUTCOME MEASURES

Selected progestogens were used: progesterone, hydroxyprogesterone, dydrogesterone, medrogestone, medroxyprogesterone acetate, promegestone, dienogest, and intrauterine levonorgestrel. For each progestogen, use was defined by at least one dispensation within the year before the index date (within three years for 13.5 mg levonorgestrel intrauterine systems and five years for 52 mg). Conditional logistic regression was used to calculate odds ratio for each progestogen meningioma association.

RESULTS

Mean age was 57.6 years (standard deviation 12.8). Analyses showed excess risk of meningioma with use of medrogestone (42 exposed cases/18 061 cases (0.2%) v 79 exposed controls/90 305 controls (0.1%), odds ratio 3.49 (95% confidence interval 2.38 to 5.10)), medroxyprogesterone acetate (injectable, 9/18 061 (0.05%) v 11/90 305 (0.01%), 5.55 (2.27 to 13.56)), and promegestone (83/18 061 (0.5%) v 225/90 305 (0.2 %), 2.39 (1.85 to 3.09)). This excess risk was driven by prolonged use (≥one year). Results showed no excess risk of intracranial meningioma for progesterone, dydrogesterone, or levonorgestrel intrauterine systems. No conclusions could be drawn concerning dienogest or hydroxyprogesterone because of the small number of individuals who received these drugs. A highly increased risk of meningioma was observed for cyproterone acetate (891/18 061 (4.9%) v 256/90 305 (0.3%), odds ratio 19.21 (95% confidence interval 16.61 to 22.22)), nomegestrol acetate (925/18 061 (5.1%) v 1121/90 305 (1.2%), 4.93 (4.50 to 5.41)), and chlormadinone acetate (628/18 061 (3.5%) v 946/90 305 (1.0%), 3.87 (3.48 to 4.30)), which were used as positive controls for use.

CONCLUSIONS

Prolonged use of medrogestone, medroxyprogesterone acetate, and promegestone was found to increase the risk of intracranial meningioma. The increased risk associated with the use of injectable medroxyprogesterone acetate, a widely used contraceptive, and the safety of levonorgestrel intrauterine systems are important new findings.

Variability in the Arterial Supply of Intracranial Meningiomas: An Anatomic Study

BACKGROUND AND OBJECTIVES

Intracranial meningiomas are a diverse group of tumors, which vary by grade, genetic composition, location, and vasculature. Expanding the understanding of the supply of skull base (SBMs) and non-skull base meningiomas (NSBMs) will serve to further inform resection strategies. We sought to delineate the vascular supply of a series of intracranial meningiomas by tumor location.

METHODS

A retrospective study of intracranial meningiomas that were studied using preoperative digital subtraction angiograms before surgical resection at a tertiary referral center was performed. Patient, tumor, radiologic, and treatment data were collected, and regression models were developed.

RESULTS

One hundred sixty-five patients met inclusion criteria. The mean age was 57.1 years (SD: 12.6). The mean tumor diameter was 4.9 cm (SD: 1.5). One hundred twenty-six were World Health Organization Grade I, 37 Grade II, and 2 Grade III. Arterial feeders were tabulated by Al-Mefty's anatomic designations. SBMs were more likely to derive arterial supply from the anterior circulation, whereas NSBMs were supplied by external carotid branches. NSBMs were larger (5.61 cm vs 4.45 cm, P = <.001), were more often presented with seizure (20% vs 8%, P = .03), were higher grade ( P = <.001) had more frequent peritumoral brain edema (84.6% vs 66%, P = .04), and had more bilateral feeders (47.7% vs 28%, P = .01) compared with SBMs. More arterial feeders were significantly associated with lower tumor grade ( P = .023, OR = 0.59). Higher tumor grade (Grade II/III) was associated with fewer arterial feeders ( P = .017, RR = 0.74).

CONCLUSION

Meningioma location is associated with specific vascular supply patterns, grade, and patient outcomes. This information suggests that grade I tumors, especially larger tumors, are more likely to have diverse vascular supply patterns, including internal carotid branches. This study may inform preoperative embolization and surgical considerations, particularly for large skull base tumors.

Spheno-Orbital Meningioma - Treatment Outcomes and Factors Influencing Recurrence

PURPOSE

To determine treatment outcomes, recurrence rates, and predictors of recurrence, to inform future therapeutic approaches for spheno-orbital meningiomas (SOM).

METHODS

A retrospective single-center study of SOM treated from 1990 to 2021 was conducted with comprehensive neuro-ophthalmologic follow-up at Columbia University Medical Center (CUMC). Recurrence requiring reintervention was defined clinically as worsening of visual acuity, visual field defect, or ocular motility after an initial period of stabilization or 6 months of improvement following treatment, or radiologically as either a regrowth with an increase in tumor size by 20% at the site of previous growth or a new region of tumor growth.

RESULTS

In total 46 patients met the inclusion criteria. The mean follow-up was 106 months (range 1-303). Dictated by the phenotype of the disease, patients underwent either gross- (50%), near- (17%), or subtotal resection (26%). Removal of the anterior clinoid process (ACP) was performed in 52% of patients. Nine patients (20%) required an enucleation or exenteration. Radiotherapy was employed at some point of treatment in 50% of cases. Inherited cases (24%) were referred to CUMC for treatment following 1 or more recurrences. The total recurrence rate, including inherited cases, was 54%, occurring at a mean interval of 43 months. The recurrence rate of patients treated solely at CUMC was 40%, occurring at a mean interval of 41 months. A subset of patients (32%) had 2 or more recurrences. Histopathology at the first surgery was WHO grade I (87%) and II (13%) and at the final surgery was WHO grade I (74%), II (21%), and III (4%). A subset of grade I tumors that received radiotherapy (35%) evolved to a higher grade or developed multiple recurrences without a change in histologic grade I. Grade II tumors and treatment with radiotherapy increased the odds of recurrence. Removal of the ACP and gross total resection decreased the odds of recurrence.

CONCLUSION

Due to the routinely long interval to tumor recurrence, lifelong surveillance of patients with SOM is prudent. ACP resection and gross total resection, where possible, reduce tumor recurrence and the need for further treatment. Radiotherapy should be reserved for higher-grade meningiomas and select grade I tumors.

Meningiomas of the rolandic region: risk factors for motor deficit and role of intra-operative monitoring

OBJECTIVE

Meningiomas of the rolandic region are associated to high risk of postoperative motor deficits. This study discusses the factors affecting motor outcome and recurrences from the analysis of a monoinstitutional case series and eight studies from a literature review.

METHODS

Data of 75 patients who underwent surgery for meningioma of the rolandic region were retrospectively reviewed. The analyzed factors included tumor location and size, clinical presentation, magnetic resonance imaging (MRI) and surgical findings, brain-tumor interface, extent of resection, postoperative outcome and recurrence. Eight studies from literature on rolandic meningiomas treated with or without intraoperative monitoring (IOM) were reviewed with the aim to define the impact of IOM on the extent of resection and motor outcome.

RESULTS

Among the 75 patients of the personal series, the meningioma was on the brain convexity in 34 (46%), at the parasagittal region in 28 (37%) and at the falx in 13 (17%). The brain-tumor interface was preserved in 53 cases (71%) at MRI and in 56 (75%) at surgical exploration. Simpson grade I resection was obtained in 43% of patients, grade II in 33%, grade III in 15% and grade IV in 9%. The motor function worsened postoperatively in 9 among 32 cases with preoperative deficit (28%) and in 5 among 43 with no preoperative deficit (11.5%); definitive motor deficit was evidenced in overall series at follow-up in 7 (9.3%). Patients with meningioma with lost arachnoid interface had significant higher rates of worsened postoperative motor deficit (p = 0.01) and seizures (p = 0.033). Recurrence occurred in 8 patients (11%). The analysis of the 8 reviewed studies (4 with and 4 without IOM) shows in the group without IOM higher rates of Simpson grades I and II resection (p = 0.02) and lower rates of grades IV resection (p = 0.002); no significant differences in postoperative immediate and long-term motor deficits were evidenced between the two groups.

CONCLUSIONS

Data from literature review show that the use of IOM does not affect the postoperative motor deficit Therefore, its role in rolandic meningiomas resection remains to be determined and will be defined in further studies.

De Novo Skull Base Atypical Meningioma: Incidence and Outcome

Objective  Atypical meningiomas are uncommon in skull base practice and present a management challenge. We aimed to review all de novo atypical skull base meningioma cases within a single unit to analyze presentation and outcome. Methods  A retrospective review of all patients undergoing surgery for intracranial meningioma identified consecutive cases of de novo atypical skull base meningioma. Electronic case records were analyzed for patient demographics, tumor location and size, extent of resection, and outcome. Tumor grading is based on the 2016 WHO criteria. Results  Eighteen patients with de novo atypical skull base meningiomas were identified. The most common tumor location was the sphenoid wing in 10 patients (56%). Gross total resection (GTR) was achieved in 13 patients (72%) and subtotal resection (STR) in 5 patients (28%). There was no tumor recurrence recorded in patients who had undergone GTR. Patients with tumors >6 cm were more likely to undergo a STR as opposed to a GTR ( p  < 0.01). Patients who had undergone a STR were more likely to have postoperative tumor progression and be referred for radiotherapy ( p  = 0.02 and <0.01, respectively). On multiple regression analysis, tumor size is the only significant factor correlating with overall survival ( p  = 0.048). Conclusion  The incidence of de novo atypical skull base meningioma is higher in our series than currently published data. Tumor size was a significant indicator for patient outcome and extent of resection. Those undergoing a STR were more likely to have tumor recurrence. Multicenter studies of skull base meningiomas with associated molecular genetics are needed to guide management.

Prognosis and histology of sporadic synchronous and metachronous meningiomas and comparative analyses with singular lesions

Synchronous or metachronous growth of multiple tumors (≥ 2) is found in up to 20% of meningioma patients. However, biological as well as histological features and prognosis are largely unexplored. Clinical and histological characteristics were retrospectively investigated in 95 patients harboring 226 multiple meningiomas (MMs) and compared with 135 cases of singular meningiomas (SM) using uni- and multivariate analyses. In MM, tumors occurred synchronously and metachronously in 62% and 38%, respectively. WHO grade was intra-individually constant in all but two MMs, and histological subtype varied in 13% of grade 1 tumors. MM occurred more commonly in convexity/parasagittal locations, while SM were more frequent at the skull base (p < .001). In univariate analyses, gross total resection (p = .014) and high-grade histology in MM were associated with a prolonged time to progression (p < .001). Most clinical characteristics and rates of high-grade histology were similar in both groups (p ≥ .05, each). Multivariate analyses showed synchronous/metachronous meningioma growth (HR 4.50, 95% CI 2.26-8.96; p < .001) as an independent predictor for progression. Compared to SM, risk of progression was similar in cases with two (HR 1.56, 95% CI .76-3.19; p = .224), but exponentially raised in patients with 3-4 (HR 3.25, 1.22-1.62; p = .018) and ≥ 5 tumors (HR 13.80, 4.06-46.96; p < .001). Clinical and histological characteristics and risk factors for progression do not relevantly differ between SM and MM. Although largely constant, histology and WHO grade occasionally intra-individually vary in MM. A distinctly higher risk of disease progression in MM as compared to SM might reflect different underlying molecular alterations.

Current Knowledge on Spinal Meningiomas Epidemiology, Tumor Characteristics and Non-Surgical Treatment Options: A Systematic Review and Pooled Analysis (Part 1)

BACKGROUND

Spinal meningiomas are the most common primary intradural spinal tumors. Although they are a separate entity, a large portion of the knowledge on spinal meningiomas is based on findings in intracranial meningiomas. Therefore, a comprehensive review of all the literature on spinal meningiomas was performed.

METHODS

Electronic databases were searched for all studies on spinal meningiomas dating from 2000 and onward. Findings of matching studies were pooled to strengthen the current body of evidence.

RESULTS

A total of 104 studies were included. The majority of patients were female (72.83%), elderly (peak decade: seventh), and had a world health organization (WHO) grade 1 tumor (95.7%). Interestingly, the minority of pediatric patients had a male overrepresentation (62.0% vs. 27.17%) and higher-grade tumors (33.3% vs. 4.3%). Sensory and motor dysfunction and pain were the most common presenting symptoms. Despite a handful of studies reporting promising findings associated with the use of non-surgical treatment options, the literature still suffers from contradictory results and limitations of study designs.

CONCLUSIONS

Elderly females with WHO grade 1 tumors constituted the stereotypical type of patient. Compared to surgical alternatives, the evidence for the use of non-surgical treatments is still relatively weak.

Predictive Power of MIB-1 vs. Mitotic Count on Progression-Free Survival in Skull-Base Meningioma

Simple Summary

Meningiomas are mainly benign intracranial tumors. Nevertheless, risk of recurrence exists in long-term follow-up, so new prognostic markers are still need to be identified. MIB-1 is no diagnostic criterion in WHO classification of meningiomas by now. This retrospective study shows that MIB-1 as well as mitotic count are good predictors for progression-free survival in skull-base meningiomas. The implantation of MIB-1 may enable an improved classification of meningiomas regarding progression-free survival. Moreover, this analysis of skull-base meningiomas shows that current cut-offs may have to be adjusted for meningioma location.

Abstract

Although meningiomas are mainly non-aggressive and slow-growing tumors, there is a remarkable recurrence rate in a long-term follow-up. Proliferative activity and progression-free survival (PFS) differs significantly among the anatomic location of meningiomas. The aim of the present study was to investigate the predictive power of MIB-1 labeling index and mitotic count (MC) regarding the probability of PFS in the subgroup of skull-base meningiomas. A total of 145 patients were included in this retrospective study. Histopathological examinations and follow-up data were collected. Ideal cut-off values for MIB-1 and MC were ≥4.75 and ≥6.5, respectively. MIB-1 as well as MC were good predictors for PFS in skull-base meningiomas. Time-dependent analysis of MIB-1 and MC in prediction of recurrence of skull-base meningioma showed that their prognostic values were comparable, but different cut-offs for MC should be considered regarding the meningioma’s location. As the achievement of a gross total resection can be more challenging in skull-base meningiomas and second surgery implies a higher risk profile, the recurrence risk could be stratified according to these findings and guide decision-making for follow-ups vs. adjuvant therapies.

Growth risk classification and typical growth speed of convexity, parasagittal, and falx meningiomas: a retrospective cohort study

OBJECTIVE

Meningiomas are the most common primary intracranial tumors, and their clinical and biological characteristics vary by location. Convexity, parasagittal, and falx meningiomas account for approximately 50%-65% of intracranial meningiomas. Focusing only on these locations, the aim of this study was to determine the typical speed of tumor growth, to assess the growth risk, and to show the possible tumor volume that many lesions can reach after 5 years.

METHODS

Patients with radiologically suspected convexity, parasagittal, or falx meningiomas at the authors' institution were studied retrospectively. The relative growth rate (RGR) and annual volume change (AVC) were calculated from MRI at more than 3-month intervals. Based on sex, age, and signal intensity on T2-weighted MRI, the cases were classified into three groups: extremely high-growth, high-growth, and low-growth groups.

RESULTS

The data of 313 cases were analyzed. The median RGR and AVC for this entire cohort were 6.1% (interquartile range [IQR] 2.4%-16.0%) and 0.20 (IQR 0.04-1.18) cm3/year, respectively. There were significant differences in sex (p = 0.018) and T2-weighted MRI signal intensity (p < 0.001) for RGR, and T2-weighted MRI signal intensity (p < 0.001), tumor location (p = 0.025), and initial tumor volume (p < 0.001) for AVC. The median RGR and AVC were 17.5% (IQR 8.3%-44.1%) and 1.05 (IQR 0.18-3.53) cm3/year, 8.2% (IQR 2.9%-18.6%) and 0.33 (IQR 0.06-1.66) cm3/year, and 3.4% (IQR 1.2%-5.8%) and 0.04 (IQR 0.02-0.21) cm3/year for the extremely high-growth, high-growth, and low-growth groups, respectively, with a significant difference among the groups (p < 0.001). A 2.24-times, or 5.24 cm3, increase in tumor volume over 5 years was typical in the extremely high-growth group, whereas the low-growth group showed little change in tumor volume even over a 5-year follow-up period.

CONCLUSIONS

For the first time, the typical speed of tumor growth was calculated, focusing only on patients with convexity, parasagittal, and falx meningiomas. In addition, the possible tumor volume that many lesions in these locations can reach after 5 years was shown based on objective indicators. These results may allow clinicians to easily detect lesions that require frequent follow-up or early treatment by determining whether they deviate from the typical range of the growth rate, similar to a growth chart for children.

Low-Dose Acetylsalicylic Acid Treatment in Non-Skull-Base Meningiomas: Impact on Tumor Proliferation and Seizure Burden

MIB-1 index is an important predictor of meningioma progression and was found to be correlated with COX-2 expression. However, the impact of low-dose acetylsalicylic acid (ASA) on MIB-1 index and clinical symptoms is unclear. Between 2009 and 2022, 710 patients with clinical data, tumor-imaging data, inflammatory laboratory (plasma fibrinogen, serum C-reactive protein) data, and neuropathological reports underwent surgery for primary cranial WHO grade 1 and 2 meningioma. ASA intake was found to be significantly associated with a low MIB-1 labeling index in female patients ≥ 60 years. Multivariable analysis demonstrated that female patients ≥ 60 years with a non-skull-base meningioma taking ASA had a significantly lower MIB-1 index (OR: 2.6, 95%: 1.0–6.6, p = 0.04). Furthermore, the intake of ASA was independently associated with a reduced burden of symptomatic epilepsy at presentation in non-skull-base meningiomas in both genders (OR: 3.8, 95%CI: 1.3–10.6, p = 0.03). ASA intake might have an anti-proliferative effect in the subgroup of elderly female patients with non-skull-base meningiomas. Furthermore, anti-inflammatory therapy seems to reduce the burden of symptomatic epilepsy in non-skull-base meningiomas. Further research is needed to investigate the role of anti-inflammatory therapy in non-skull-base meningiomas.

Risk of intracranial meningioma with three potent progestogens: a population-based case-control study

Background and purpose

A dose‐dependent association between the use of cyproterone acetate (CPA) and intracranial meningioma has been identified but data for other potent progestogens are scarce. The association was assessed between intracranial meningioma surgery and exposure to three potent progestogens: CPA (≥25 mg/day), nomegestrol acetate (NOMAC) (3.75–5 mg/day) and chlormadinone acetate (CMA) (2–10 mg/day).

Methods

In this nationwide population‐based case–control study, cases underwent surgery for intracranial meningioma in France from 2009 to 2018. They were matched to five control subjects for sex, year of birth and area of residence. Progestogen exposure was defined as progestogen use within the year before surgery for cases or the same date for their controls.

Results

In total, 25,216 cases were included (75% women, median age 58 years). Progestogen exposure was noted for 9.9% of cases (2497/25,216) and 1.9% (2382/126,080) of controls, with an odds ratio (OR) of 6.7 (95% confidence interval [CI] 6.3–7.1). The OR was 1.2 (1.0–1.4) for short‐term use (<1 year) and 9.5 (8.8–10.2) for prolonged use. A strong association was identified for prolonged use of CPA (OR = 22.7, 95% CI 19.5–26.4), NOMAC (OR = 6.5, 95% CI 5.8–7.2) and CMA (OR = 4.7, 95% CI 4.5–5.3). Progestogen exposure increased the risk of meningioma for all histological grades and anatomical sites, particularly for the anterior and middle skull base: OR = 35.7 (95% CI 26.5–48.2) and 23.9 (95% CI 17.8–32.2) for CPA. The estimated number of attributable cases was 2124 (95% CI 2028–2220) (212/year).

Conclusion

A strong association between prolonged exposure to potent progestogens and surgery for meningioma was observed. The risk increased from CMA to NOMAC to CPA. Individuals should be informed of this risk.

This study highlights a strong association between prolonged use of nomegestrol and chlormadinone acetate (two potent progestogens) and intracranial meningioma, although weaker than that of cyproterone acetate. The estimated number of cases was higher than 2000 in France over 10 years.

Predictive Factors of Favorable Visual Outcomes After Surgery of Tuberculum Sellae Meningiomas: A Multicenter Retrospective Cohort Study

BACKGROUND

Because of their proximity to the visual structures, tuberculum sellae meningiomas are frequently revealed by ophthalmologic impairment. The goal of surgery is gross total resection and improvement of visual function. The purpose of the present study was to identify the predictors of favorable visual outcomes after surgery of tuberculum sellae meningioma.

METHODS

We retrospectively collected tuberculum sellae meningiomas treated at 2 neurosurgical centers from 2010 to 2020. We collected the clinical, imaging and surgical data and analyzed their effects on the visual outcome. A favorable visual outcome was defined as an increase in visual acuity of ≥0.2 point and/or an increase of >25% of the visual field or complete recovery.

RESULTS

A total of 50 patients were included. At 4 months after surgery, 30 patients (60%) had experienced visual improvement. The predictors of a favorable visual outcome were a symptom duration of <6 months, preoperative visual acuity >0.5, a smaller tumor size, and tumor with T2-weighted/fluid attenuated inversion recovery hypersignal on magnetic resonance imaging. During surgery, a soft tumor and a clear brain-tumor interface were associated with favorable visual outcomes. Preoperative optic coherence tomography measurements of the retinal nerve fiber layer thickness >80 μM and ganglion cell complex thickness >70 μM were also associated with a better ophthalmologic outcome.

CONCLUSIONS

In tuberculum sellae meningiomas, rapid surgical treatment must be performed to optimize vision improvement. A hyperintense lesion on T2-weighted/fluid attenuated inversion recovery magnetic resonance imaging and minor vision impairment at the initial ophthalmologic presentation might give hope for a favorable outcome. Performing optic coherence tomography measurements before surgery could clarify patients' expectations regarding their recovery.

Clinical and pathological impact of an optimal assessment of brain invasion for grade 2 meningioma diagnosis: lessons from a series of 291 cases

Brain invasion has not been recognized as a standalone criterion for atypical meningioma by the WHO classification until 2016. Since the 2007 edition suggested that meningiomas harboring brain invasion could be classified as grade 2, brain invasion study was progressively strengthened in our center, based on a strong collaboration between neurosurgeons and neuropathologists regarding sample orientation and examination. Practice changes were considered homogeneous enough in 2011. The aim of the present study was to evaluate the impact of gross practice change on the clinical and pathological characteristics of intracranial meningiomas classified as grade 2.The characteristics of consecutive patients with a grade 2 meningioma surgically managed before (1998-2005, n = 125, group A) and after (2011-2014, n = 166, group B) practices changed were retrospectively reviewed.Sociodemographical and clinical parameters were comparable in groups A and B, and the median age was 62 years in both groups (p = 0.18). The 5-year recurrence rates (23.2% vs 29.5%, p = 0.23) were similar. In group A, brain invasion was present in 48/125 (38.4%) cases and was more frequent than in group B (14/166, 8.4%, p < 0.001). In group A, 33 (26.4%) meningiomas were classified as grade 2 solely based on brain invasion (group A_SBI), and 92 harbored other grade 2 criteria (group A_OCA). Group A_SBI meningiomas had a similar median progression-free survival compared to groups A_OCA (68 vs 80 months, p = 0.24) and to A_OCA and B pooled together (n = 258, 68 vs 90 months, p = 0.42).An accurate assessment of brain invasion is mandatory as brain invasion is a strong predictor of meningioma progression.

Proliferative Potential, and Inflammatory Tumor Microenvironment in Meningioma Correlate with Neurological Function at Presentation and Anatomical Location-From Convexity to Skull Base and Spine

Simple Summary

The World Health Organization (WHO) classification grades meningiomas exclusively due to their histopathological features. Meningiomas are predominantly benign intracranial entities, and surgical resection represents the therapy of choice. However, risk of progression and tailored scheduling of follow-up appointments are significantly influenced by various items, such as immunohistochemistry (e.g., MIB-1 index). Emerging evidence focuses attention on the anatomic location of meningiomas, especially regarding the differentiation between skull base and non-skull base meningiomas. In the present study, we therefore investigated demographic, histopathological, and laboratory variables regarding their association with the anatomic location. We found that spinal meningiomas have a significantly lower proliferative activity, less density of macrophage infiltrates, and a longer time to tumor progression. Moreover, increased MIB-1 indices are significantly associated with location-specific baseline symptoms (e.g., convexity: seizure burden, medial skull base: decreased vision, spinal: ambulatory ability). Therefore, anatomic location might be considered as a future subclassification in the grading of the prognosis of meningiomas.

Abstract

Emerging evidence emphasizes the prognostic importance of meningioma location. The present investigation evaluates whether progression-free survival (PFS), proliferative potential, World Health Organization (WHO) grades, and inflammatory burden differ between anatomical locations (skull base, non-skull base, and spinal) meningiomas. Five-hundred-forty-one patients underwent Simpson grade I or II resection for WHO grade 1 or 2 meningiomas. Univariable analysis revealed that spinal meningioma patients are significantly older, had a worse baseline Karnofsky Performance Status (KPS), higher acute-phase protein levels, lower incidence of WHO grade 2, lower mitotic counts, lower MIB-1 index, and less CD68⁺ macrophage infiltrates. Multivariable analysis identified WHO grade 2 (OR: 2.1, 95% CI: 1.1–3.7, p = 0.02) and cranial location (OR: 3.0, 95% CI: 1.8–4.9, p = 0.001) as independent predictors of diffuse CD68⁺ macrophage infiltrates. The mean PFS in cranial meningiomas was 115.9 months (95% CI: 107.5–124.3), compared to 162.2 months (95% CI: 150.5–174.0; log-rank test: p = 0.02) in spinal meningiomas. Multivariable Cox regression analysis revealed cranial location as an independent predictor (HR: 4.7, 95% CI: 1.0–21.3, p = 0.04) of shortened PFS. Increased MIB-1 indices ≥5% were significantly associated with location-specific deficits at presentation, such as decreased vision and seizure burden. Spinal meningiomas have a significantly longer PFS time and differ from the cranial meningiomas regarding MIB-1 index and density of tumor-associated macrophages.

A systematic review and meta-analysis of the association between cyproterone acetate and intracranial meningiomas

The influence of exposure to hormonal treatments, particularly cyproterone acetate (CPA), has been posited to contribute to the growth of meningiomas. Given the widespread use of CPA, this systematic review and meta-analysis attempted to assess real-world evidence of the association between CPA and the occurrence of intracranial meningiomas. Systematic searches of Ovid MEDLINE, Embase and Cochrane Controlled Register of Controlled Trials, were performed from database inception to 18th December 2021. Four retrospective observational studies reporting 8,132,348 patients were included in the meta-analysis. There was a total of 165,988 subjects with usage of CPA. The age of patients at meningioma diagnosis was generally above 45 years in all studies. The dosage of CPA taken by the exposed group (n = 165,988) was specified in three of the four included studies. All studies that analyzed high versus low dose CPA found a significant association between high dose CPA usage and increased risk of meningioma. When high and low dose patients were grouped together, there was no statistically significant increase in risk of meningioma associated with use of CPA (RR = 3.78 [95% CI 0.31–46.39], p = 0.190). Usage of CPA is associated with increased risk of meningioma at high doses but not when low doses are also included. Routine screening and meningioma surveillance by brain MRI offered to patients prescribed with CPA is likely a reasonable clinical consideration if given at high doses for long periods of time. Our findings highlight the need for further research on this topic.

Management of cavernous sinus meningiomas: Consensus statement on behalf of the EANS skull base section

Introduction

The evolution of cavernous sinus meningiomas (CSMs) might be unpredictable and the efficacy of their treatments is challenging due to their indolent evolution, variations and fluctuations of symptoms, heterogeneity of classifications and lack of randomized controlled trials. Here, a dedicated task force provides a consensus statement on the overall management of CSMs.

Research question

To determine the best overall management of CSMs, depending on their clinical presentation, size, and evolution as well as patient characteristics.

Material and methods

Using the PRISMA 2020 guidelines, we included literature from January 2000 to December 2020. A total of 400 abstracts and 77 titles were kept for full-paper screening.

Results

The task force formulated 8 recommendations (Level C evidence). CSMs should be managed by a highly specialized multidisciplinary team. The initial evaluation of patients includes clinical, ophthalmological, endocrinological and radiological assessment. Treatment of CSM should involve experienced skull-base neurosurgeons or neuro-radiosurgeons, radiation oncologists, radiologists, ophthalmologists, and endocrinologists.

Discussion and conclusion

Radiosurgery is preferred as first-line treatment in small, enclosed, pauci-symptomatic lesions/in elderly patients, while large CSMs not amenable to resection or WHO grade II-III are candidates for radiotherapy. Microsurgery is an option in aggressive/rapidly progressing lesions in young patients presenting with oculomotor/visual/endocrinological impairment. Whenever surgery is offered, open cranial approaches are the current standard. There is limited experience reported about endoscopic endonasal approach for CSMs and the main indication is decompression of the cavernous sinus to improve symptoms. Whenever surgery is indicated, the current trend is to offer decompression followed by radiosurgery.

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A thorough evaluation of cavernous sinus meningiomas by a multidisciplinary team is mandatory.

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Microsurgery should be considered for aggressive lesions in young patients.

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Extended endoscopic approaches can be effective when combined with radiotherapy.

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Stereotaxic radiotherapy and stereotaxic radiosurgery offer excellent tumour control in small/asymptomatic lesions .

How Much Tumor Volume Is Responsible for Development of Clinical Symptoms in Patients With Convexity, Parasagittal, and Falx Meningiomas?

Purpose: Meningiomas are the most common primary intracranial neoplasms and clinical symptom appearance depends on their volume and location. This study aimed to identify factors that influence clinical symptoms and to determine a specific threshold tumor volume for the prediction of symptomatic progression in patients with convexity, parasagittal, and falx meningiomas.

Materials and Methods: We retrospectively studied patients with radiologically suspected convexity, parasagittal, or falx meningiomas at our institution.

Results: The data of three hundred thirty-three patients were analyzed. We further divided patients into two groups based on clinical symptoms: an asymptomatic group (250 cases) and a symptomatic group (83 cases). Univariate analysis revealed significant differences between the groups in terms of sex (p = 0.002), age at the time of volumetric analysis (p < 0.001), hyperintense lesions on T2-weighted images (p = 0.029), peritumoral edema (p < 0.001), maximum tumor diameter (p < 0.001), and tumor volume (p < 0.001). Further multivariate analysis revealed significant differences between the groups in terms of age at the time of volumetric analysis (p = 0.002), peritumoral edema (p < 0.001), and tumor volume (p < 0.001). The receiver operating characteristic curve revealed a threshold tumor volume of 21.1 ml for predicting whether a patient would develop symptoms (sensitivity 0.843, specificity 0.880, an area under the curve 0.919 [95% confidence interval: 0.887–0.951]).

Conclusion: We identified factors predictive of clinical symptoms in patients with convexity, parasagittal, and falx meningiomas and determined the first-ever threshold tumor volume for predicting symptomatic progression in such patients.

Consensus core clinical data elements for meningiomas

BACKGROUND

With increasing molecular analyses of meningiomas, there is a need to harmonize language used to capture clinical data across centers to ensure that molecular alterations are appropriately linked to clinical variables of interest. Here the International Consortium on Meningiomas presents a set of core and supplemental meningioma-specific Common Data Elements (CDEs) to facilitate comparative and pooled analyses.

METHODS

The generation of CDEs followed the four-phase process similar to other National Institute of Neurological Disorders and Stroke (NINDS) CDE projects: discovery, internal validation, external validation, and distribution.

RESULTS

The CDEs were organized into patient- and tumor-level modules. In total, 17 core CDEs (10 patient-level and 7-tumour-level) as well as 14 supplemental CDEs (7 patient-level and 7 tumour-level) were defined and described. These CDEs are now made publicly available for dissemination and adoption.

CONCLUSIONS

CDEs provide a framework for discussion in the neuro-oncology community that will facilitate data sharing for collaborative research projects and aid in developing a common language for comparative and pooled analyses. The meningioma-specific CDEs presented here are intended to be dynamic parameters that evolve with time and The Consortium welcomes international feedback for further refinement and implementation of these CDEs.

Expression of Progesterone Receptor and Its Association with Clinicopathological Characteristics in Meningiomas: A Cross-Sectional Study

BACKGROUND

Meningiomas that are progesterone receptor positive have a low recurrence rate and good prognosis compared to those that are progesterone receptor negative. This study aimed to determine the prevalence of expression of progesterone in meningiomas and its association with clinicopathological characteristics.

MATERIALS AND METHODS

This was a cross-sectional laboratory-based study that was conducted at Muhimbili National Hospital. The study included 112 formalin-fixed paraffin-embedded tissue blocks of patients who were confirmed to have meningiomas on histological basis from January 2010 to December 2014. Immunohistochemical expression of progesterone receptor was tested using a primary monoclonal progesterone receptor antibody ready to use (IR 068 Dako). The χ2 test was used to determine the association between clinicopathological characteristics and progesterone receptor expression. A 2-tailed P < 0.05 was considered significant.

RESULTS

The mean age of the patients was 45.5 ± 3.601 years, and majority (66.1%, n = 74) were in the age group between 31 and 60 years. Also, majority of the patients (60%, n = 67) in this study were females. Over one-third of the cases (34.8%, n = 39) comprised of meningotheliomatous subtype, and majority of the cases (89.3%, n = 100) were of grade I. The prevalence of progesterone expression was 54.5% (n = 61), and only age was associated with progesterone receptor expression (P = 0.043).

CONCLUSION

The finding of high expression of the progesterone receptor for grade I cases in this study indicates that progesterone receptor expression in meningiomas is of prognostic value and may be considered when evaluating patients for management. Lack of expression of progesterone receptor in all the malignant cases is intriguing and needs further studies that can investigate its prognostic role.

Progesterone Receptor Expression in Meningiomas: Pathological and Prognostic Implications

Background

The progesterone receptor (PR) is variably expressed in most meningiomas and was found to have prognostic significance. However, the correlation with patient age, tumor location, time to recurrence, and pattern of regrowth has scarcely been discussed.

Methods

A surgical series of 300 patients with meningiomas is reviewed. The PR expression was classified as: 0. absent; 1. low (<15%); 2. moderately low (16-50%); 3. moderately high (51-79%); 4. high (≥80%). The PR values were correlated with the patient age and sex, meningioma location, WHO grade, Ki-67 MIB1, recurrence rate, pattern of recurrence (local-peripheral versus multicentric diffuse), and time to recurrence.

Results

The PR expression has shown lower rate of high expression in the elderly group (p = 0.032) and no sex difference (including premenopausal versus postmenopausal women), higher expression in medial skull base and spinal versus other locations (p = 0.0036), inverse correlation with WHO grade and Ki67-MIB1 (p < 0.0001). Meningiomas which recurred showed at initial surgery higher rates of low or moderately low PR expression than the non-recurrent ones (p = 0.0004), whereas the pattern of regrowth was not significant. Higher rates of PR values ≥80% were found in cases with time to recurrence >5 years (p = 0.036).

Conclusion

The higher PR expression in medial skull base meningiomas, the significant correlation with the time to recurrence, the lack of difference of PR expression between premenopausal and postmenopausal women and between local-peripheral versus multicentric-diffuse recurrences are the most relevant unreported findings of this study. The rate of PR expression must be included in the routine pathological diagnosis of meningiomas because of its prognostic significance.

WHO grade III meningioma: De novo tumors show improved progression free survival as compared to secondary progressive tumors

Emerging evidence suggest WHO grade III meningiomas that arise de novo as opposed to dedifferentiating from a lower grade may harbor differing prognoses. To investigate this, a single institution retrospective analysis of prospectively acquired patients between 1999 and 2018 was performed. Clinical data and radiographic parameters were reviewed to calculate progression free survival and overall survival in patients undergoing microsurgical resection. Next generation targeted sequencing of meningioma associated genes was performed on 11 tumors. Eighteen patients were identified as undergoing surgical resection of WHO grade III meningioma. Nine patients (50%) had de novo arising tumors and nine patients had secondary progressive tumors. To compare outcomes, only those patients undergoing gross total resection (Simpson grade I) were included for survival analysis. There was an improvement in median progression free survival for de novo resected tumors as compared to secondary progressive tumors (p = 0.02). Median overall survival for patients with de novo tumors was not statistically improved compared to that of secondary progressive tumors (p = 0.22). Next generation sequencing of targeted genes (NF2, BAP1, TRAF7, KLF4, SMO and AKT) revealed 5/11 tumors containing mutations in the NF2 gene, 2/11 containing BAP1 mutations, and a single tumor containing mutations in both NF2 and TRAF7. More mutations in NF2 and BAP1 were seen in the secondary progressive tumors. In conclusion, patients undergoing gross total resection for de novo arising grade III meningiomas showed improved progression free survival, though similar overall survival, as compared to those patients with secondary progressive tumors. Further studies focused on tumor associated genes and other associated risk factors are needed to improve risk-stratification.

The Impact of 5-Year Tumor Doubling Time to Predict the Subsequent Long-Term Natural History of Asymptomatic Meningiomas

OBJECTIVE

Meningiomas are the most frequent primary brain tumors. The long-term natural history of asymptomatic meningiomas remains unclear and difficult to predict accurately, however. The purpose of this study was to determine the subsequent course of asymptomatic meningiomas preceded by 5 years of no treatment.

METHODS

We retrospectively studied patients with radiologically suspected intracranial asymptomatic meningiomas preceded by 5 years of no treatment. We volumetrically measured the lesions' chronological changes during the initial 5 years to obtain the 5-year tumor doubling time (5y-TdT).

RESULTS

A total of 201 cases met the inclusion criteria. They were further divided into 3 subgroups: those who remained asymptomatic (group A; 174 cases), those who developed neurological symptoms and underwent treatment (group B; 8 cases), and those who received intentional intervention for a preventative reason (group C; 19 cases). 5y-TdT of group B (median: 46.5 months) was significantly shorter than that of group A (median: 216.3 months) (P < 0.001). Progression-free survival (PFS) was significantly different between tumors that exhibited 5y-TdT ≥ 98.8 months and <98.8 months (P < 0.001). When we combined groups B and C and set the PFS endpoint as either disease progression or treatment, we found that more than 20% of patients would require treatment within 15 years.

CONCLUSIONS

The present study revealed the subsequent course of asymptomatic meningiomas after 5 years of no treatment and demonstrated that 5y-TdT is useful to detect patients who may require treatment.

STA-MCA Bypass in Carotid Stenosis after Radiosurgery for Cavernous Sinus Meningioma

BACKGROUND

Cavernous sinus meningiomas (CSM) are mostly non-surgical tumors. Stereotactic radiosurgery (SRS) or radiotherapy (SRT) allow tumor control and improvement of pre-existing cranial nerve (CN) deficits. We report the case of a patient with radiation-induced internal carotid artery (ICA) stenosis. We complete the picture with a review of the literature of vascular and non-vascular complications following the treatment of CSMs with SRS or SRT.

METHODS

After a case description, a systematic literature review is presented, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2015 guidelines.

RESULTS

115 abstracts were screened and 70 titles were retained for full-paper screening. A total of 58 articles did not meet the inclusion criteria. There were 12 articles included in our review, with a follow-up ranging from 33 to 120 months. Two cases of post-SRT ischemic stroke and one case of asymptomatic ICA stenosis were described. Non-vascular complications were reported in all articles.

CONCLUSION

SRS and SRT carry fewer complications than open surgery, with similar rates of tumor control. Our case shows the importance of a follow-up of irradiated CSMs not only by a radio-oncologist, but also by a neurosurgeon, illustrating the importance of multidisciplinary management of CSMs.

Meningiomas in Gynecology and Reproduction: an Updated Overview for Clinical Practice

There is various evidence to suggest a relationship between female hormones and meningiomas; as clinicians, we often come to face challenging situations involving female patients diagnosed with meningiomas during the post-pubertal phases of their life. We aimed to review the specific circumstances (pregnancy, postpartum, hormonal contraception and hormone replacement therapy, gender-affirming hormonal treatment) clinicians might come to face during their daily clinical practice, given the absence of available guidelines. We therefore conducted a narrative review on articles found in PubMed and Embase databases using appropriate keywords. Ninety-six relevant articles were included. The available evidence on managing meningiomas in post-pubertal women often implies personal strategies, highlighting the lack of a unified approach. The knowledge of the biological links between female hormones and meningiomas is fundamental to correctly counsel patients in various life phases. Prospective randomized studies are required to improve available guidelines on how to best manage meningiomas in female post-pubertal patients.

Characterization of Progesterone Receptor Expression in Intracranial Meningiomas of Patients Treated in a High-Complexity Hospital in Bogota, Colombia

Background Meningiomas are the single most common brain tumor. The incidence of these tumors increases with age; different studies have shown that meningiomas usually appear after the age of 50. These tumors are more common in women than in men, and women are twice as likely to suffer from the condition. Surgery is the primary form of treatment, which can be curative with complete resection. If the tumor is unresectable or other treatments such as surgery and radiotherapy have failed, hormonal therapy or chemotherapy may be considered. There is limited information about the clinical, demographic, and histopathological characteristics of these tumors in the population of Bogotá, Colombia. Objective To evaluate the expression of progesterone receptors in patients over 18 years old who have been diagnosed with meningiomas in a high-complexity hospital in Bogota, Colombia, and to describe the demographic and histopathological characteristics of these patients. Methods This is a descriptive and retrospective case series. Patients with meningioma who underwent surgical resection at a high-complexity hospital in Bogota, Colombia, from 2016 to 2019 were retrospectively identified and studied. Demographic variables, such as age and gender, were extracted from the clinical chart. Indirect immunoperoxidase staining was carried out for the progesterone receptor (PR) and Ki67. PR is analyzed as positive and negative, and the Ki67 proliferation index was determined. Results Thirty-two meningiomas from patients who underwent surgery were available for analysis. Twenty-five (78.1%) were positive for PR, 71.8% were females, and 93% were World Health Organization (WHO) grade I. Meningothelial (28%), fibrous (25%), and transitional (25%) meningiomas were the most frequent subtypes, correspondingly. The Ki67 mean value was 1.14 (0.11-10.71). Conclusion Our case series showed a greater frequency of meningiomas in women, with a high PR expression and a low Ki67 proliferation rate. These data correlate with literature worldwide.

Meningiomas in Premenopausal Women: Role of the Hormone Related Conditions

Background

Several epidemiological and pathological findings suggest that the female sex hormones may influence the development of meningiomas. However, the role of pregnancy, oral contraceptives, and fertilization therapies is still controversial.

Methods

From the surgical series of 354 patients with meningiomas operated between 2006 and 2019, the group of 72 premenopausal women was separately considered. The tumor location, WHO grade, Ki67-labeling index (LI), progesterone receptor (PR) expression, and histological types were studied in premenopausal women with and without hormone-related conditions were compared.

Results

In this premenopausal group, 24 patients had hormone-related conditions, including use of oral contraceptives in 16, intrauterine fertilization in one, pregnancy in three, and tumors of the female reproductive system in four. The group of patients with hormone-related conditions, as compared to that with no hormone related conditions, showed slightly lower median age (38 versus 43 years) and no significant difference of meningioma location WHO grade, Ki 67-Li, PR expression and histological type. The clinical onset during pregnancy in three patients and tumor growth during contraceptive progesterone therapy in two others were evidenced.

Conclusion

The biological behavior of meningiomas and their pathological findings, including PR expression, are not correlated with the different hormone related conditions in premenopausal female patients. Contraceptives and fertilization therapies, mainly with progesterone, should be avoided in patients with meningiomas.

Expression of GLUT3 and HIF-1α in Meningiomas of Various Grades Correlated with Peritumoral Brain Edema

Aim

To investigate the expression of glucose transporter 3 (GLUT3) and hypoxia-inducible factor-1α protein (HIF-1α) in meningiomas and analyze the correlation between GLUT3 and HIF-1α expression with the pathological grade of peritumoral brain edema (PTBE) of meningiomas.

Methods

In this cross-sectional study, we analyzed meningioma specimens from 160 patients collected from January 1, 2014, to December 1, 2017, by dividing them into a low-grade (WHO I) or high-grade (WHO II and WHO III) group. Immunohistochemical analyses were used to detect the expression level of GLUT3 and HIF-1α in the tumor specimens.

Results

The proportion of GLUT3-positive staining in tumors sized <4 cm, 4–6 cm, and>6 cm was 35.9% (37/103), 63.6% (28/44), and 53.8% (7/13), respectively (P = 0.007). The proportion of HIF-1α-positive staining in tumors sized <4 cm, 4–6 cm, and >6 cm was 41.7% (43/103), 68.2% (30/44), and 38.5% (5/13), respectively (P = 0.010). The proportion of GLUT3-positive staining in the high-grade group and low-grade group was 70.8% (34/48) and 33.9% (38/112), respectively (P < 0.001). The proportion of HIF-1α-positive staining in the high-grade group and low-grade group was 62.5% (30/48) and 42.9% (48/112), respectively (P = 0.023). GLUT3-positive expression in meningioma PTBE grades 0, I, II, and III was 20.3% (13/64), 41.2% (14/34), 63.6% (21/33), and 82.8% (24/29), respectively (Bonferroni-corrected, P < 0.001, α/6 = 0.008). HIF-1α-positive expression in meningioma PTBE grades 0, I, II, and III was 34.4% (22/64), 47.1% (16/34), 54.5% (18/33), and 75.9% (22/29), respectively (Bonferroni-corrected, P = 0.003, α/6 = 0.008). Spearman's correlation analysis revealed a correlation between the expression of GLUT3 and HIF-1α in meningiomas (r = 0.463, P < 0.001). Multivariate analysis revealed that GLUT3-positive expression, HIF-1α-positive expression, and high pathological grade were associated with the development of PTBE (P < 0.05).

Conclusions

GLUT3 and HIF-1α expression in meningiomas was closely related to the tumor size, pathological grade, and PTBE. This study is the first to report a unique map-like multifocal GLUT3 staining pattern in meningiomas.

The Preferred Locations of Meningioma According to Different Biological Characteristics Based on Voxel-Wise Analysis

Objective: Meningiomas presented preferred intracranial distribution, which may reflect potential biological natures. This study aimed to analyze the preferred locations of meningioma according to different biological characteristics. Method: A total of 1,107 patients pathologically diagnosed with meningiomas between January 2012 and December 2016 were retrospectively analyzed. Preoperative MRI were normalized, and lesions were semiautomatically segmented. The stereospecific frequency and p value heatmaps were constructed to compare two biological phenotypes using two-tailed Fisher's exact test. Age, sex, WHO grades, extent of resection (EOR), recurrence, and immunohistochemical markers including p53, Ki67, epithelial membrane antigen (EMA), progesterone receptor (PR), and CD34 were statistically analyzed. Recurrence-free survival (RFS) were analyzed by Kaplan-Meier method. Result: Of 1,107 cases, convexity (20.8%), parasagittal (16.1%), and falx (11.4%) were the most predominant loci of meningiomas. The p-value heatmap suggested lesion predominance in the left frontal and occipital convexity among older patients while in the left sphenoid wing, and right falx, parasellar/cavernous sinus, and middle fossa among younger patients. Lesions located at anterior fossa and frontal structures were more frequently seen in the male while left parietal falx and tentorial regions, and right cerebellopontine angle in the female. Grades II and III lesions presented predominance in the frontal structures compared with grade I ones. Meningiomas at the left parasagittal sinus and falx, tentorium, intraventricular regions, and skull-base structures were significantly to receive subtotal resection. Lesions with p53 positivity were statistically located at the left frontal regions and parasellar/cavernous sinus, higher Ki67 index at the left frontal and bilateral parietal convexity and right parasellar/cavernous sinus, EMA negativity at the right olfactory groove and left middle fossa, and CD34 positivity at the sellar regions and right sphenoid wing. Tumor recurrence rates for grades I, II, and III were 2.8, 7.9, and 53.8%, respectively. Inferior RFS, higher Ki67 index, grades II and III, and a larger preoperative volume were observed in older patients. Recurrent meningiomas were more frequently found at the occipital convexity, tentorium, sellar regions, parasagittal sinus, and left sphenoid wing. Conclusion: The preferred locations of meningioma could be observed according to different biological characteristics, which might be helpful for clinical decisions.

Parasellar Meningiomas

Parasellar spaces remain particularly singular, comprising the most important neurovascular structures such as the internal carotid artery and optic, oculomotor, and trigeminal nerves. Meningiomas are one of the most frequent tumors arising from parasellar spaces. In this location, meningiomas remain mostly benign tumors with WHO grade I and a meningothelial subtype. Progestin intake should be investigated and leads mostly to conservative strategies. In the case of benign nonsymptomatic tumors, observation should be proposed. Tumor growth will lead to the proposition of surgery or radiosurgery. In the case of an uncertain diagnosis and an aggressive pattern, a precise diagnosis is required. For cavernous sinus and Meckel's cave lesions, complete removal is rarely considered, leading to the proposition of an endoscopic endonasal or transcranial biopsy. Optic nerve decompression could also be proposed via these approaches. A case-by-case discussion about the best approach is recommended. A transcranial approach remains necessary for tumor removal in most cases. Vascular injury could lead to severe complications. Cerebrospinal fluid leakage, meningitis, venous sacrifice, visual impairment, and cranial nerve palsies are more frequent complications. Pituitary dysfunctions are rare in preoperative assessment and in postoperative follow-up but should be assessed in the case of meningiomas located close to the pituitary axis. Long-term follow-up is required given the frequent incomplete tumor removal and the risk of delayed recurrence. Radiosurgery is relevant for small and well-limited meningiomas or intra-cavernous sinus postoperative residue, whereas radiation therapy and proton beam therapy are indicated for large, extended, nonoperable meningiomas. The place of the peptide receptor radionuclide therapyneeds to be defined. Targeted therapy should be considered in rare, recurrent, and aggressive parasellar meningiomas.