Endocrine manipulation of meningiomas with medroxyprogesterone acetate. Effect of MPA on growth of primary meningioma cells in monolayer tissue culture

The Role of Mifepristone in Meningiomas Management: A Systematic Review of the Literature

OBJECTIVES

We performed a systematic literature review to analyze the clinical application and the safety of mifepristone, a prominent antiprogesterone agent, in meningioma patients.

MATERIALS AND METHODS

A systematic search was performed through Medline, Cochrane, and clinicaltrials.gov databases from 1960 to 2014. Study Selection. Studies were selected through a PICO approach. Population was meningioma patients, meningioma cells cultures, and animal models. Intervention was mifepristone administration. Control was placebo administration or any other drug tested. Outcomes were clinical and radiological responsiveness, safety profile, and cell growth inhibition.

RESULTS

A total of 7 preclinical and 6 clinical studies and one abstract were included. Encouraging results were found in preclinical studies. Concerning clinical studies, the response rate to mifepristone in terms of radiological regression and symptomatic improvement/stability in patients with inoperable meningioma was low. In meningiomatosis, favorable preliminary results were recorded. The safety profile was good. Limitations were as follows. The tumoral expression of progesterone receptors was not analyzed systematically in every study considered.

CONCLUSIONS

No clear evidence exists to recommend mifepristone in inoperable meningiomas. Preliminary encouraging results were found in diffuse meningiomatosis. Mifepristone is a well-tolerated treatment. Patients' selection and hormonal profile analysis in meningiomas are fundamental for a better understanding of its benefit. Multicenter placebo-controlled trials are required.

Meningiomas in pregnancy: a clinicopathologic study of 17 cases

BACKGROUND

Dramatic growth of meningiomas is occasionally encountered during pregnancy. While cell proliferation is often assumed, hemodynamic changes have also been touted as a cause.

OBJECTIVE

We identified 17 meningiomas resected during pregnancy or within 3 weeks post-partum and characterized them to determine the cause of occasional rapid growth in pregnancy.

METHODS

Seventeen tumors were identified from searches at 4 university centers. All available clinical records, radiology images, and tissue specimens were reviewed, with immunohistochemical studies performed as needed.

RESULTS

Sixteen patients underwent tumor resection and 1 died of complications prior to surgery. Average patient age was 32 years. Nine experienced onset of symptoms in the third trimester or within 8 days post-partum. Principle physical findings included visual complaints (59%) and cranial nerve palsies (29%). Ten tumors (59%) were located in the skull base region. The Ki-67 labeling index was low (0.5-3.6%) in 11 of 13 benign (grade I) tumors and elevated (11-23.2%) in 3 of 4 atypical (grade II) meningiomas. Eight (50%) tumors featured hypervascularity with at least focal CD34-positive hemangioma-like microvasculature. Fourteen (82%) showed evidence of intra- and/or extracellular edema, 1 so extensive that its meningothelial nature was not apparent. Five tumors (29%) exhibited intratumoral hemorrhage and/or necrosis.

CONCLUSION

Our series suggests that pregnancy-associated meningiomas located in the skull base are likely to require surgical intervention for visual complaints and cranial nerve palsies. The rapid tumor growth is more often due to potentially reversible hemodynamic changes rather than hormone-induced cellular proliferation.

Expression of estrogen receptors alpha and beta in human meningiomas

The predominance of meningiomas in females, their accelerated growth during the luteal phase of the menstrual cycle and during pregnancy; and the association between meningiomas and breast cancer has led to a number of studies examining the potential role of steroids on the growth of meningiomas. It is generally agreed that the majority of meningiomas possess the progesterone and androgen receptor. There are numerous discrepancies in the literature among the results for estrogen receptor (ER). The aim of this study was to examine the expression of ER-alpha mRNA and the recently described novel ER, ER-beta in meningiomas. Using reverse transcription and polymerase chain reaction (RT-PCR) Southern blot analysis thirty-four meningiomas were examined for the presence of ER-alpha and ER-beta. Forty-four percent of meningiomas showed a strong band for ER-beta mRNA and sixty-eight percent of meningiomas showed a strong band for ER-alpha mRNA. The involvement of ER-beta in meningioma biology should be examined further, given the differences in the ER-alpha and ER-beta gene products.

Inverse correlation of cell proliferation and expression of progesterone receptors in tumor spheroids and monolayer cultures of human meningiomas

OBJECTIVE

The progesterone receptor (PgR) can be detected in 60 to 70% of meningiomas using immunohistochemistry] in situ. Whereas in monolayer tissue cultures the PgR is only rarely expressed, we were able recently to demonstrate the preservation of the PgR in fragment spheroid cultures of meningiomas. The aim of the present study was to evaluate the stability of PgR expression in meningioma spheroids in vitro and the correlation of PgR expression and cell proliferation in spheroids and whether meningioma cells reaggregated to spheroids from monolayer cultures to reexpress the PgR again.

METHODS

Tumor fragment spheroids (Weeks 1-6) and cell monolayers (Passages 1 and 3) of 15 PgR-positive meningiomas were investigated by immunohistochemistry for the expression of PgRs and their proliferative activity, as demonstrated by positivity for the proliferation-related antigen Ki-67. To study PgR reexpression in reaggregated spheroids, Northern blots were performed. In addition, a reverse transcriptase-polymerase chain reaction technique was established and evaluated in combination with immunohistochemistry. Growth of meningioma spheroids was quantified in the presence of progesterone and the specific antagonist onapristone.

RESULTS

The PgR remained stable in spheroids for 6 weeks in 9 of 13 cases that were able to be evaluated. All tumor fragment spheroids exhibited a proliferation index of 5 to 40% Ki-67-positive cells. Monolayer cell cultures, on the other hand, failed to express PgRs but revealed higher proliferation indices (40-90%) to a significant extent. The detection of PgR messenger ribonucleic acid in reaggregated spheroids by means of reverse transcriptase-polymerase chain reaction correlated to the nuclear expression of PgR in immunohistochemistry. Neither progesterone nor its antagonist onapristone altered spheroid growth in vitro.

CONCLUSION

The expression of the PgR in meningiomas is preserved in spheroid cultures with low proliferation indices for at least 6 weeks, whereas monolayer cell cultures with a high proliferative activity lack PgR expression. The inverse pattern of Ki-67-positive cells in the outer regions of the spheroids and PgR-expressing tumor cells in the spheroid centers leads us to the conclusion that proliferating meningioma tumor cells do not express PgRs. This might also explain why tumor cell growth in vitro was neither affected by progesterone nor by onapristone. Monolayer cell cultures can be reaggregated to spheroids, the consequence being a reexpression of PgRs and, therefore, a down-regulation of proliferation.

Chemotherapy for meningiomas

The most efficacious treatment for meningiomas is surgery. For incompletely resected or recurrent tumors, radiotherapy can be given. However, when the meningioma is unresectable and/or all other previous treatments have failed, immunotherapy or chemotherapy may be considered for malignant tumors and immunotherapy and hormone therapy may be considered for benign ones. Various chemotherapy treatments that have shown some efficacy in individual cases include combinations of Adriamycin and Dacarbazine or Ifosfamide and Mesna. The most effective immunotherapy appears to be administration of interferon-alpha, which is relatively non-toxic and easily tolerated. However, more studies are needed to better define the roles of these agents in the management of a recurrent, unresectable, or malignant meningiomas.

Progesterone receptors in tumor fragment spheroids of human meningiomas

Progesterone receptors (PgR) are detectable in about 60-70% of tissue specimens of human meningiomas. Despite these data, PgR are hardly to be found in monolayer tissue culture of meningiomas. Aim of this study was to elucidate whether PgR might be preserved in tumor fragment spheroids of meningiomas maintained in organ culture since the morphological appearance of the original tumor is preserved by this culture technique. Aliquots of meningioma specimens of 25 patients (17 females) were snap frozen in liquid nitrogen immediately after removal. Additionally, monolayer tissue cultures of the same specimen were obtained as primary culture and passage #3. Tumor fragment spheroids were kept on medium-agar with liquid medium overlay and harvested after 1 and 3 weeks in culture. PgR were detected by immunohistochemistry using a rat monoclonal antibody. 18/25 meningioma tissue specimens were positive for PgR. In 8 out of 15 PgR-positive tumors which formed spheroids we could detect PgR in fragment spheroids after 1 and 3 weeks in culture. In contrast, none of the monolayers depicted PgR. PgR is preserved in a considerable amount of tumor fragment spheroids of PgR-positive meningiomas. They remain detectable after 3 weeks of culture whereas monolayer tissue cultures are PgR-negative. Thus, tumor fragment spheroids seem to be a suitable tool to investigate progesterone/antiprogesterone effects in vitro.

TGF alpha expression in meningioma--tumor progression and therapeutic response

Little is known of the molecular genetic mechanisms contributing to meningioma tumor progression. We evaluated a total of 26 clinical cases of meningioma: twenty three patients with meningioma treated at our institution between 1978 and 1990 and three asymptomatic cases found initially at autopsy. In addition, histologically normal meninges obtained at post-mortem examination from 5 cases were evaluated. There were 13 men and 10 women in the patient group with a median age of 48.7 years, treated by surgery and/or irradiation. Median follow-up was 46 months (range 16-152 months). Archival cases and age-matched normal meningeal tissue obtained at autopsy during the same time period were obtained for study. Patients with TGF alpha scores greater than 3.0 were more likely to fail treatment and had lower overall survival times than those with immunostaining scores of 1 or 2. Three autopsy cases where meningioma had been silent clinically had overall staining scores of 0.75, while 10 samples of normal meninges harvested from 5 cases at autopsy had staining scores of 0. Two patients each underwent 3 surgeries for recurrent tumor, serial specimens showed increased TGF alpha expression over time, though all material from these procedures was consistent with the diagnosis of histologically benign meningioma.

[Endocrine treatment of meningiomas: a review]

Meningiomas are benign tumors of central nervous system. They have high rates of relapse and sometimes are not amenable to total removal mainly when involve vital structures. Clinical, epidemiological, biochemical and "in vitro" experiment show evidence that meningioma growth is influenced by steroid hormonal medium. Several clinical trials have explored these meningioma characteristics with the use of substances interfering with steroid actions: RU486 (antiprogestinic and antiglucocorticoid), medroxiprogesterone acetate (antiprogestinic), gestrinone (antiestrogenic e antiprogestinic), tamoxifen (antiestrogenic) and buserelin (LHRH superagonist), beyond of octreotide (somatostatin analog) and bromocriptine (dopaminergic agonist). Other substances have potential for the meningiomas treatment: aminogluthetimide, suramin and trapidil. In this review, we analyzed the literature about these aspects.

Intracranial meningiomas: analysis of recurrence after surgical treatment

Recurrence of intracranial meningiomas after surgery has long been recognized, but there is still no consensus about factors responsible for recurrence. To better understand such factors, we analysed data on 276 patients with meningiomas who were treated at our institution from 1976 to 1990 (mean follow-up = 5.1 years). Effects of sex, tumour histology, tumour site, and radiotherapy on recurrence were closely studied. Using World Health Organization criteria to define malignancy, 254 of the tumours were benign and 22 were atypical or malignant. For data analysis, distinction was made between "recurrence"(i.e., reappearance of tumour after total resection) and "regrowth" (i.e., tumour enlargement after subtotal removal). Recurrence was seen in 2 of 183 benign meningiomas and in 10 of 16 malignant meningiomas. Recurrence and regrowth rates for malignant meningiomas far exceeded those for benign meningiomas (p = 0.001). Neither sex nor tumour site was associated with subsequent recurrences in patients whose tumours had been completely resected. The influence of radiotherapy was studied in terms of its effects on benign versus malignant meningiomas, whether given after complete or incomplete resection, and whether given after primary resection or on reoperation. We found that radiotherapy did not decrease "recurrence" or "regrowth" regardless of when administered, either at first resection or on recurrence. This was true for benign as well as malignant meningiomas. However, due to the small number in our series, we cannot conclude that radiotherapy has no beneficial role in the treatment of meningiomas.(ABSTRACT TRUNCATED AT 250 WORDS)

Immunohistochemical detection of female sex hormone receptors in meningiomas: correlation with clinical and histological features

Sixty-one meningiomas from 60 patients were screened for estrogen receptors and progesterone receptors (PgR) with monoclonal antibodies in an immunohistochemical assay. In addition, 43 of the cases were evaluated for tumor size and peritumoral edema, as seen on computed tomographic scans and magnetic resonance images. Sixty-one percent of the tumors contained significant amounts of PgR, whereas no estrogen receptor-positive tumor was observed. Thirteen percent of all tumors were classified as nonbenign variants (atypical and anaplastic meningiomas) and were more frequently found in male patients (P < 0.05). Nonbenign tumors more frequently showed an absence of PgR (P < 0.05), and there was a tendency for PgR-negative tumors to be larger than PgR-positive ones. No correlation was found between PgR status and edema. It is concluded that PgR status in meningiomas is related to tumor differentiation and may be of prognostic value with regard to biological behavior and clinical outcome.

Meningiomas

This article reviews the recent literature on the pathogenesis and pathology of meningiomas, contemporary techniques of surgical resection, and new nonsurgical treatments, including radiation and hormone therapy. Factors predisposing to meningioma formation include female sex, previous ionizing radiation, and Type 2 neurofibromatosis. The first factor may act through the expression of sex hormone receptors, especially the progesterone receptor, in these tumors; the other two probably act by causing a deletion on Chromosome 22. The pathological classifications of meningiomas include the traditional division into histological subtypes and the World Health Organization classification that selects characteristics that may lead to recurrence. There is an increasing emphasis on proliferative indices and other characteristics that may predict aggressive behavior in these tumors. On computed tomography, meningiomas are enhancing, well-marginated, dural-based lesions that may have considerable surrounding edema; the cause of the edema is uncertain but may result from secretory products of the tumor. Magnetic resonance imaging with enhancement will demonstrate these lesions accurately and can be used for three-dimensional reconstruction as well. Computed tomography and magnetic resonance imaging have largely replaced angiography in the preoperative diagnosis of meningiomas, but angiographic embolization may be a useful operative adjunct. Although meningioma surgery is sometimes thought of as benign and curative, the reported surgical mortality rate is as high as 14.3% and the reported 10-year survival rate after surgery varies from 43 to 77%. Surgery has advanced most in the management of suprasellar, cavernous sinus, clivus, tentorial, and posterior fossa meningiomas, because new approaches and a better understanding of anatomy have allowed more radical resection. There is still substantial morbidity associated with surgery in these regions, however, and the long-term recurrence rates are still unknown for these new radical techniques. For convexity, parasagittal, lateral sphenoid wing, and olfactory groove meningiomas, complete resection should be the goal and operative morbidity appears to be low. There is a high recurrence rate after surgery. With apparent total removal, the recurrence rate varies from 9 to 20% at 10 years, with subtotal resection varying from 18.4 to 50%. The degree of resection appears to be most important in recurrence, but histopathological features are also important. Recently, radiation therapy has been recognized as a useful adjunct to surgery, and with radiosurgical techniques may become more important in the future. Antiprogesterone therapy appears to have had some success as well, and it or other hormonal therapy may be another future option for residual or recurrent meningiomas.

Mifepristone (RU 486) treatment of meningiomas

Meningiomas are common brain tumours which are generally benign, well circumscribed and slow growing. In a minority of patients complete surgical removal is not possible and re-growth of tumour tissue is a major clinical problem. Most meningiomas contain progesterone receptors. The anti-progestational drug mifepristone (RU 486) binds to these receptors. Ten patients were treated with 12 recurrent or primary "inoperable" meningiomas, all of whom had shown recent neuroradiological and/or ophthalmological evidence of tumour growth. They received 200 mg mifepristone daily for 12 months. Most patients initially had complaints of nausea, vomiting and/or tiredness. In four patients prednisone (7.5 mg/day) was given after which these side-effects subsided. CT scan analysis of tumour size, showed progression of growth of five meningiomas in four patients, stable disease in three patients with three tumours and regression of four tumours in three patients. A decrease in the complaints of headache and an improved general well being was observed in five patients. Two patients died during the treatment period from unrelated causes. Mifepristone treatment resulted in control of tumour growth (= stable disease) in six of 10 patients who had shown recent evidence of tumour growth. In three of these six patients consistent tumour shrinkage was observed.

Monoclonal antibody Ki-67: its use in histopathology

Monoclonal antibody Ki-67 is a reliable and easy means of accurately assessing the growth fraction of human neoplasms. Although the number of long-term follow-up studies is limited, it does appear to provide valuable prognostic information particularly in lymphoproliferative disease. Since the estimation of growth fraction is only one factor influencing tumour behaviour it would be naive to believe that measurement of this parameter alone, no matter how accurately, would provide the clinician with definitive prognostic information for all tumours. The antibody is also of use in research, providing a means of measuring proliferative activity in a variety of conditions besides malignancy, and may prove of value in monitoring tumour response to established and trial therapies.

Immunocytochemical evidence of progesterone receptors in human meningiomas

The presence of progesterone receptors in meningioma tissue is demonstrated by use of highly specific monoclonal antibodies against the rabbit progesterone receptors which cross-react with human progesterone receptors in breast cancer cells, thus giving evidence of the existence of genuine progesterone receptors in human meningiomas.

Effect of steroids and antisteroids on human meningioma cells in primary culture

Human meningiomas are rich in progestin receptors but virtually devoid of oestrogen receptors. We have studied the hormonal sensitivity of meningioma cells in vitro during 8 days of primary culture in the presence of different steroids and antisteroids. On day 8 the thymidine labelling index (TLI) was determined as a measure of cell growth. To date 30 cultures have been established from 39 tissue specimens. 13 cultures had a TLI below 1.0 and their growth were not affected by hormones. The TLI of the other 17 cultures was 3.0 +/- 1.7 (mean +/- SD; range 1.2-7.7). Following culture in the presence of 1 and 10 nM progesterone TLI was 83 +/- 28% (n = 9) and 61 +/- 29% (n = 3) of that of the control cultures respectively. Although in individual cultures occasional differences were found, the overall values are not statistically different from 100. Similarly, 1 nM of oestradiol and testosterone had no effect on the TLI (n = 3). Tamoxifen at 1 nM increased the TLI to 138% in one culture and decreased it to 66% of the control in another. The antiprogestin mifepristone (RU 486) in concentrations of 0.1, 1.0, 10, 100 and 1000 nM decreased the TLI to 72 +/- 30; 54 +/- 20; 55 +/- 20; 59 +/- 18 and 65 +/- 10 respectively (n = 6-15; P less than 0.05 vs control). It is concluded that although a growth promoting effect of progestins on meningioma could not be shown, the therapeutic possibilities of antiprogestins warrant further investigation.