The Influence of Adjuvant Radiotherapy in Atypical and Anaplastic Meningiomas: A Series of 88 Patients in a Single Institution

The Impact of Molecular and Genetic Analysis on the Treatment of Patients with Atypical Meningiomas

Meningiomas represent approximately 40% of all primary tumors of the central nervous system (CNS) and, based on the latest World Health Organization (WHO) guidelines, are classified into three grades and fifteen subtypes. The optimal treatment comprises gross total tumor resection. The WHO grade and the extent of tumor resection assessed by the Simpson grading system are the most important predictors of recurrence. Atypical meningiomas, a grade 2 meningioma, which represent almost a fifth of all meningiomas, have a recurrence rate of around 50%. Currently, different histopathologic, cytogenetic, and molecular genetic alterations have been associated with different meningioma phenotypes; however, the data are insufficient to enable the development of specific treatment plans. The optimal treatment, in terms of adjuvant radiotherapy and postoperative systemic therapy in atypical meningiomas, remains controversial, with inconclusive evidence in the literature and existing studies. We review the recent literature to identify studies investigating relevant atypical meningioma biomarkers and their clinical application and effects on treatment options.

Ki-67 labeling index predicts tumor progression patterns and survival in patients with atypical meningiomas following stereotactic radiosurgery

PURPOSE

This study investigated whether Ki-67 labeling index (LI) correlated with clinical outcomes after SRS for atypical meningiomas.

METHODS

This retrospective study examined 39 patients with atypical meningiomas who underwent SRS over a 10-year study period. Ki-67 LI was categorized into 3 groups: low (< 5%), intermediate (5%-10%), and high (> 10%). Local tumor control rates (LCRs), progression-free rates (PFRs), disease-specific survival (DSS) rates, and adverse radiation-induced events (AREs) were evaluated.

RESULTS

The median follow-up periods were 26 months. SRS was performed at a median prescription dose of 18 Gy for tumors with a median Ki-67 LI of 9.6%. The 3-year LCRs were 100%, 74%, and 25% in the low, intermediate, and high LI groups, respectively (p = 0.011). The 3-year PFRs were 100%, 40%, and 0% in the low, intermediate, and high LI groups (p = 0.003). The 5-year DSS rates were 100%, 89%, and 50% in the low, intermediate, and high LI groups (p = 0.019). Multivariable Cox proportional hazard analysis showed a significant correlation of high LI with lower LCR (hazard ratio [HR], 3.92; 95% confidence interval [CI] 1.18-13.04, p = 0.026), lower PFR (HR 3.80; 95% CI 1.46-9.88, p = 0.006), and shorter DSS (HR 6.55; 95% CI 1.19-35.95, p = 0.031) compared with intermediate LI. The ARE rates were minimal (8%) in the entire group.

CONCLUSION

Patients with high Ki-67 LI showed significantly more tumor progression and tumor-related death. Ki-67 LI might offer valuable predictive insights for the post-SRS management of atypical meningiomas.

Health-related quality of life and clinical outcome after radiotherapy of patients with intracranial meningioma

This retrospective, single-institutional study investigated long-term outcome, toxicity and health-related quality of life (HRQoL) in meningioma patients after radiotherapy. We analyzed the data of 119 patients who received radiotherapy at our department from 1997 to 2014 for intracranial WHO grade I-III meningioma. Fractionated stereotactic radiotherapy (FSRT), intensity modulated radiotherapy (IMRT) or radiosurgery radiation was applied. The EORTC QLQ-C30 and QLQ-BN20 questionnaires were completed for assessment of HRQoL. Overall survival (OS) for the entire study group was 89.6% at 5 years and 75.9% at 10 years. Local control (LC) at 5 and 10 years was 82.4% and 73.4%, respectively. Local recurrence was observed in 22 patients (18.5%). Higher grade acute and chronic toxicities were observed in seven patients (5.9%) and five patients (4.2%), respectively. Global health status was rated with a mean of 59.9 points (SD 22.3) on QLQ-C30. In conclusion, radiotherapy resulted in very good long-term survival and tumor control rates with low rates of severe toxicities but with a deterioration of long-term HRQoL.

Establishment and Validation of an Integrated Model to Predict Postoperative Recurrence in Patients With Atypical Meningioma

Background

This study aims to establish an integrated model based on clinical, laboratory, radiological, and pathological factors to predict the postoperative recurrence of atypical meningioma (AM).

Materials and Methods

A retrospective study of 183 patients with AM was conducted. Patients were randomly divided into a training cohort (n = 128) and an external validation cohort (n = 55). Univariable and multivariable Cox regression analyses, the least absolute shrinkage and selection operator (LASSO) regression analysis, time-dependent receiver operating characteristic (ROC) curve analysis, and evaluation of clinical usage were used to select variables for the final nomogram model.

Results

After multivariable Cox analysis, serum fibrinogen >2.95 g/L (hazard ratio (HR), 2.43; 95% confidence interval (CI), 1.05–5.63; p = 0.039), tumor located in skull base (HR, 6.59; 95% CI, 2.46-17.68; p < 0.001), Simpson grades III–IV (HR, 2.73; 95% CI, 1.01–7.34; p = 0.047), tumor diameter >4.91 cm (HR, 7.10; 95% CI, 2.52–19.95; p < 0.001), and mitotic level ≥4/high power field (HR, 2.80; 95% CI, 1.16–6.74; p = 0.021) were independently associated with AM recurrence. Mitotic level was excluded after LASSO analysis, and it did not improve the predictive performance and clinical usage of the model. Therefore, the other four factors were integrated into the nomogram model, which showed good discrimination abilities in training cohort (C-index, 0.822; 95% CI, 0.759–0.885) and validation cohort (C-index, 0.817; 95% CI, 0.716–0.918) and good match between the predicted and observed probability of recurrence-free survival.

Conclusion

Our study established an integrated model to predict the postoperative recurrence of AM.

Adjuvant radiotherapy for atypical meningiomas is associated with improved progression free survival

PURPOSE

To assess the progression-free survival benefits of adjuvant radiotherapy (ART) following surgical resection compared to surgery alone in high-grade meningioma patients.

METHODS

We retrospectively identified 43 patients with atypical meningiomas, who underwent either radiotherapy post-surgical resection (Surgery+ART) or surgery alone (Surgery alone) at our institution between February 2007 to March 2019. GTR was achieved in 28 patients, and STR, in 11. Patient, meningioma, and treatment data were extracted from records and compared using Kaplan-Meier methodology, log-rank tests, and Cox proportional hazard models. Radiation complications were also evaluated.

RESULTS

Overall 32.6% (n = 14) of patients, 6 patients in the Surgery+ART group and 8 in the Surgery alone group, experienced recurrence. In the Surgery+ART group, the median PFS time was 46.5 months (CI: [35.8-50.6]), compared to 24.5 months (CI: [18.3-32.9]) in the Surgery alone group. 2-year PFS for Surgery+ART was 100% vs. 69.0% for Surgery alone, and the 5-year PFS rate was 70.6% and 39.2%, respectively (log-rank p-value = .004).

CONCLUSIONS

Our data revealed a significant PFS increase for those treated with adjuvant radiotherapy following surgery compared to surgery alone. Future prospective studies evaluating differing radiation modalities and dosages should be conducted.

Scalp Invasion by Atypical or Anaplastic Meningioma Is a Risk Factor for Development of Systemic Metastasis

BACKGROUND

Atypical and anaplastic meningiomas (AAMs) are rare and comprise approximately 5% of all meningiomas. Extracranial metastases in meningioma patients occur in 0.1% of all cases, but these lesions are difficult to treat and may be a poor prognostic factor.

METHODS

We conducted a retrospective chart review between 1990 and 2016 of patients who had surgical resection of AAM. In a cohort of 149 patients, 6 had metastatic lesions that were histologically confirmed to be meningioma. We compared baseline characteristics between patients with and without metastasis and performed a multivariate Cox regression analysis to assess risk factors for the development of systemic metastasis.

RESULTS

Six patients had histologically confirmed meningioma metastasis. We hypothesized that the presence of scalp invasion in patients could be a potential risk factor for the development of systemic meningioma metastasis. Nine out of the 149 patients without metastasis had scalp invasion, whereas 4 out of the 6 patients with metastasis had scalp invasion. Patients with metastasis had a median age of 62 ± 20. Patients without metastasis had a median age of 59 ± 15 years. Gender distribution was similar; approximately 50% of patients in each group were female. Eighty-five percent of patients with metastatic disease were white, and 65% of patients without metastatic disease were white. Among patients without metastatic disease, 77% had World Health Organization II tumors, whereas 50% of patients with metastatic disease had World Health Organization II tumors. In multivariate analysis including age, tumor grade, size, location, extent of resection, sex, and scalp invasion, the only significant predictor of systemic metastasis was scalp invasion (odds ratio = 39.67; 95% confidence interval = 3.74-421.12; P = 0.0023). Median overall survival (OS) with metastasis was 126 months, and median OS without metastasis was 158 months. Having metastatic disease was not significantly associated with worse OS (P = 0.33).

CONCLUSIONS

Metastasis development from AAM is a rare but serious event. Because scalp invasion is a strongly associated predictive factor for development of systemic metastasis in patients with AAM, it is necessary to consider strategies to prevent and to be vigilant of the development of scalp invasion.

Differentially Expressed MicroRNAs in Radioresistant and Radiosensitive Atypical Meningioma: A Clinical Study in Chinese Patients

Background: For atypical meningiomas (AMs), the combination of gross total resection (GTR) and adjuvant radiotherapy (ART) is still a controversial therapeutic strategy to improve prognosis. This study analyzed the factors influencing the prognosis on AM patients treated with GTR + ART by investigating both clinical characteristics and the change in microRNA (miRNA) expression.

Materials and Methods: Adult AM patients who were admitted to the Tiantan hospital from 2008 to 2015 and underwent GTR + ART were included. Patients who suffered recurrence within 3 years after operation were considered radioresistant, while the others were considered radiosensitive. Clinical characterizations were compared between these two groups. The microRNA (miRNA) expression was detected via miRNA microarray in 10 patients, five from the radiosensitive group and from the radioresistant group.

Results: A total of 55 cases were included in this study. No significant difference was found in the clinical characteristics (gender, age, tumor location, tumor size, peritumoral brain edema, and Ki-67 index) between radiosensitive and radioresistant patients. We found seven significantly upregulated miRNAs (miR-4286, miR-4695-5p, miR-6732-5p, miR-6855-5p, miR-7977, miR-6765-3p, miR-6787-5p) and seven significantly downregulated miRNAs (miR-1275, miR-30c-1-3p, miR-4449, miR-4539, miR-4684-3p, miR-6129, miR-6891-5p) in patients resistant to radiotherapy. The differentially expressed miRNAs were enriched mostly in the fatty acid metabolic pathways (hsa00061, hsa01212) and transforming growth factor beta signaling pathway (hsa04350).

Conclusion: For AM patients treated with GTR + ART, the changes in miRNA expression discovered in this study may be a potential predictor of individual sensitivity to adjuvant radiotherapy. Further research is needed regarding the predictive power and mechanism by which these miRNAs influence prognosis.

Impact of postoperative radiotherapy on recurrence of primary intracranial atypical meningiomas

BACKGROUND

Atypical meningiomas (WHO grade II) have high recurrence rate. However, data on the effect of radiotherapy (RT) is still conflicting. The aim of this study was to evaluate the influence of postoperative RT on the recurrence of primary atypical intracranial meningiomas.

METHODS

The medical records of all patients who underwent surgery (2007-2017 in 4 neurosurgical departments) for a histologically diagnosed primary atypical meningioma were reviewed to assess progression-free survival (PFS) and prognostic factors.

RESULTS

This analysis included 258 patients with a median age of 60 years (54.7% female). The predominant tumor locations were convexity and falx (60.9%) followed by the skull base (37.2%). Simpson grade I-II resection was achieved in 194 (75.2%) patients, Simpson grade III-IV in 53 patients (20.5%). Tumor progressed in 54 cases (20.9%). Postoperative RT was performed in 46 cases (17.8%). RT was more often applied after incomplete resection (37.7% vs. 13.4% Simpson III-IV vs. I-II). A multivariate analysis showed a significantly shorter PFS associated with Simpson III-IV [HR 1.19, (95% CI) 1.09-1.29, p < 0.001] and age > 65 years [HR 2.89, (95% CI) 1.56-5.33, p = 0.001]. A subgroup analysis with a minimal follow-up of 36 months revealed that Simpson III-IV [HR 3.01, 95% CI 1.31-6.931.03-1.24, p = 0.009] and age > 65 years [HR 2.48, 95% CI 1.20-5.13, p = 0.014] reduced PFS. The impact of postoperative RT on PFS remained statistically insignificant, even in a propensity-score matched survival analysis [n = 46; p = 0.438; OR 0.710 (0.299-1.687)].

CONCLUSIONS

In the present study, postoperative RT did not improve PFS. The most important prognostic factors remain the extent of resection and age.

Efficacy of adjuvant radiotherapy for atypical and anaplastic meningioma

The effect of adjuvant radiotherapy in management for high-grade meningiomas, especially atypical meningiomas, remains controversial. We aimed to explore the role of adjuvant radiotherapy in this population. A total of 162 adults with high-grade meningiomas (99 atypical meningiomas and 63 anaplastic meningiomas) were treated from 2003 to 2008 at Huashan Hospital. One hundred and seventeen patients presented with primary and 45 with recurrent disease. One hundred and fifteen patients (70.9%) were treated with adjuvant radiotherapy after surgical resection. The median follow-up was 76.5 months (range 1-142 months). Kaplan-Meier survival curve and Cox proportional hazards modeling were used for analyses. Adjuvant radiotherapy was associated with prolonged progression-free survival (PFS) and overall survival (OS) in patients with newly diagnosed anaplastic meningiomas irrespective of extent of resection (PFS, P = .001; OS, P = .003). Gross total resection was the only independent prognostic factor for those with newly diagnosed atypical meningiomas (PFS, P < .001; OS, P = .012). A survival benefit for adjuvant radiation was also found in subgroup analysis of patients with high-grade meningiomas who underwent subtotal resection (PFS, P = .023; OS, P = .013). Among recurrent high-grade meningiomas, radiotherapy offered no statistically significant improvement in either PFS or OS. Adjuvant radiotherapy is associated with improved survival in patients with newly diagnosed anaplastic meningiomas and those high-grade meningiomas following subtotal resection. However, there was no significant correlation identified between postoperative radiation and outcome for recurrent high-grade meningiomas. Future prospective randomized trials may help clarify the optimal tailored treatment for patients with high-grade meningioma.

Histopathological features predictive of local control of atypical meningioma after surgery and adjuvant radiotherapy

OBEJECTIVE

The goal of this study was to investigate the impact of adjuvant radiotherapy (RT) on local recurrence and overall survival in patients undergoing primary resection of atypical meningioma, and to identify predictive factors to inform patient selection for adjuvant RT.

METHODS

One hundred eighty-two patients who underwent primary resection of atypical meningioma at a single institution between 1993 and 2014 were retrospectively identified. Patient, meningioma, and treatment data were extracted from the medical record and compared using the Kaplan-Meier method, log-rank tests, multivariate analysis (MVA) Cox proportional hazards models with relative risk (RR), and recursive partitioning analysis.

RESULTS

The median patient age and imaging follow-up were 57 years (interquartile range [IQR] 45–67 years) and 4.4 years (IQR 1.8–7.5 years), respectively. Gross-total resection (GTR) was achieved in 114 cases (63%), and 42 patients (23%) received adjuvant RT. On MVA, prognostic factors for death from any cause included GTR (RR 0.4, 95% CI 0.1–0.9, p = 0.02) and MIB1 labeling index (LI) ≤ 7% (RR 0.4, 95% CI 0.1–0.9, p = 0.04). Prognostic factors on MVA for local progression included GTR (RR 0.2, 95% CI 0.1–0.5, p = 0.002), adjuvant RT (RR 0.2, 95% CI 0.1–0.4, p < 0.001), MIB1 LI ≤ 7% (RR 0.2, 95% CI 0.1–0.5, p < 0.001), and a remote history of prior cranial RT (RR 5.7, 95% CI 1.3–18.8, p = 0.03). After GTR, adjuvant RT (0 of 10 meningiomas recurred, p = 0.01) and MIB1 LI ≤ 7% (RR 0.1, 95% CI 0.003–0.3, p < 0.001) were predictive for local progression on MVA. After GTR, 2.2% of meningiomas with MIB1 LI ≤ 7% recurred (1 of 45), compared with 38% with MIB1 LI > 7% (13 of 34; p < 0.001). Recursive partitioning analysis confirmed the existence of a cohort of patients at high risk of local progression after GTR without adjuvant RT, with MIB1 LI > 7%, and evidence of brain or bone invasion. After subtotal resection, adjuvant RT (RR 0.2, 95% CI 0.04–0.7, p = 0.009) and ≤ 5 mitoses per 10 hpf (RR 0.1, 95% CI 0.03–0.4, p = 0.002) were predictive on MVA for local progression.

CONCLUSIONS

Adjuvant RT improves local control of atypical meningioma irrespective of extent of resection. Although independent validation is required, the authors’ results suggest that MIB1 LI, the number of mitoses per 10 hpf, and brain or bone invasion may be useful guides to the selection of patients who are most likely to benefit from adjuvant RT after resection of atypical meningioma.

Impact of radiotherapy in atypical meningioma recurrence: literature review

Evaluate whether radiotherapy (RT) after the neurosurgical treatment of atypical meningiomas (AM) has an impact on the reduction rate of recurrence. A Medline search through October 2017 using "atypical meningioma" returned 1277 papers for initial review. Inclusion criteria were as follows. We analyzed the database and included articles in which the anatomic pathological classification of atypical meningiomas was in accordance with WHO 2007 or WHO 2016 criteria, patients > 18 years of age, and there was postoperative external beam radiation to the tumor bed. Exclusion criteria were WHO grade I or III meningioma, patients who underwent whole-brain radiation, RT used as salvage therapy for recurrence, palliative dose of RT (< 45 Gy), recurrent AMs, and multiple AMs. Papers reporting outcomes in which atypical and anaplastic meningiomas were analyzed together were rejected, as were papers with small samples that may compromise evaluation. After filtering our initial selection, only 17 papers were selected. After reviewing the seventeen articles including a total of 1761 patients (972 female and 799 male; 1.21 female/1.0 male), the difference in proportion of tumor recurrence between patients with and without radiotherapy after neurosurgical procedure was 1.0448, 95% CI [0.8318 to 1.3125], p value = 0.7062. On the basis of this review, there is no evidence to suggest that RT decreases the rate of recurrence in patients with atypical meningiomas.

Endoscopic Endonasal Craniofacial Surgery for Recurrent Skull Base Meningiomas Involving the Pterygopalatine Fossa, the Infratemporal Fossa, the Orbit, and the Paranasal Sinus

OBJECTIVE

Skull base meningiomas carry a nonnegligible risk of recurrence. In particular, those arising from the sphenoid wings or middle cranial fossa penetrate into extracranial regions, uncommonly showing massive expansion into the craniofacial regions on recurrence. The role of endoscopic endonasal surgery for those intractable lesions remains unclear.

METHODS

We performed endoscopic endonasal craniofacial surgery for 8 recurrent meningiomas invading into the pterygopalatine fossa, infratemporal fossa, nasopharynx, paranasal sinus, or orbit, comprising 2 meningothelial and 1 fibrous meningiomas (World Health Organization [WHO] grade I), 3 atypical and 1 clear cell meningiomas (grade II), and 1 anaplastic meningioma (grade III). All were large (15-80 cm³; median, 45 cm³) and highly vascularized.

RESULTS

All 8 tumors were sufficiently resected. Gross total resection of the craniofacial part of the lesions was achieved in 5 patients (62.5%). In 3 patients with WHO grade I meningiomas and 1 with grade II, tumors were successfully controlled as of the last follow-up. In 4 patients with WHO grade II or III meningiomas, craniofacial lesions were controlled, whereas original intracranial lesions were poorly controlled and became critical.

CONCLUSIONS

We consider the endoscopic endonasal approach as an acceptable, less-invasive alternative for recurrent craniofacial meningioma. Although all these cases were relatively large and highly vascularized, preoperative endovascular embolization of the feeding arteries contributes to significantly reducing vascularity of the tumors, and local control of the craniofacial lesions was successfully achieved in all cases. Endoscopic endonasal craniofacial surgery enabled sufficient mass reduction without disfiguring facial incisions.

Anticancer Activity of Ganoderic Acid DM: Current Status and Future Perspective

Ganoderma lucidum is a mushroom that has a long history of medicinal use in the Far East countries as this mushroom is revered for its supposed miracle cures and life improving properties. Recently, this mushroom has come under scientific scrutiny to examine the possibility of finding biologically active compounds that may have an impact on human physiology. The main category of biologically active compounds produced in the G. lucidum, are the triterpenoids, which are known as Ganoderic Acids. In this review, we discuss one Ganoderic Acid in particular known as Ganoderic Acid-DM (GA-DM) that is extracted from the Ganoderma lucidum mushroom. We will discuss GA-DM as a potential therapeutic candidate for treating a number of diseases yet will focus on the potential to be used as an alternative or supplemental therapeutic agent in regards to various cancer types. The urge for this promising therapeutic agent is that GA-DM is capable of inducing cell death in cancer cells while exhibiting minimal toxicity to normal bystander cells. Furthermore, this review will look at GA-DM's ability to stimulate an immune response in the tumor environment to potentially provide long-term protection from the malignant tumors. We will also discuss the known routes of administration of GA-DM and pose the advantages and disadvantages of each route in a comparative manner. Finally, we will cover current status of the roles GA-DM may have as a therapeutic agent in respect to different cancer types as wells as discuss about its future perspective as a therapeutic candidate in other diseases as well.

Early or late radiotherapy following gross or subtotal resection for atypical meningiomas: Clinical outcomes and local control

We report a single institution series of surgery followed by either early adjuvant or late radiotherapy for atypical meningiomas (AM). AM patients, by WHO 2007 definition, underwent subtotal resection (STR) or gross total resection (GTR). Sixty-three of a total 115 patients then received fractionated or stereotactic radiation treatment, early adjuvant radiotherapy (≤4months after surgery) or late radiotherapy (at the time of recurrence). Kaplan Meier method was used for survival analysis with competing risk analysis used to assess local failure. Overall survival (OS) at 1, 2, and 5years for all patients was 87%, 85%, 66%, respectively. Progression free survival (PFS) at 1, 2, and 5years for all patients was 65%, 30%, and 18%, respectively. OS at 1, 2, and 5years was 75%, 72%, 55% for surgery alone, and 97%, 95%, 75% for surgery+radiotherapy (log-rank p-value=0.0026). PFS at 1, 2, and 5years for patients undergoing surgery without early adjuvant radiotherapy was 64%, 49%, and 27% versus 81%, 73%, and 59% for surgery+early adjuvant radiotherapy (log-rank p-value=0.0026). The cumulative incidence of local failure at 1, 2, and 5years for patients undergoing surgery without early External Beam Radiation Therapy (EBRT) was 18.7%, 35.0%, and 52.9%, respectively, versus 4.2%, 13.3%, and 20.0% for surgery and early EBRT (p-value=0.02). Adjuvant radiotherapy improves OS in patients with AM. Early adjuvant radiotherapy improves PFS, likely due to the improvement in local control seen with early adjuvant EBRT.

Prognostic factors for patients with World Health Organization grade III meningiomas treated at a single center

We analyzed the characteristics of patients with World Health Organization (WHO) grade III meningioma to identify factors that may predict tumor recurrence and overall survival (OS).We retrospectively reviewed the patients diagnosed with WHO grade III meningioma who were surgically treated at our institute between 2008 and 2016. Survival outcome was assessed by Kaplan-Meier analysis. Cox regression analyses were performed to identify the prognostic factors associated with tumor recurrence and OS.Forty-two patients were included. The mean follow-up time was 23.2 months (range 2-75 months). At the end of analysis, 30 patients were found with tumor recurrence. The 1-year, 3-year, and 5-year recurrence-free survival (RFS) were 51.6%, 33.9%, and 12.0%, respectively. At final follow-up, 23 patients were deceased, the 1-year, 3-year, and 5-year OS were 66.2%, 39.7%, and 35.8%, respectively. Twenty-eight newly diagnosed patients were included, and the 1-year, 3-year, and 5-year RFS were 63.5%, 44.3%, and 19.4%, respectively, and the 1-year, 3-year, and 5-year OS were 74.6%, 52.5%, and 46.7%, respectively. Extent of resection was the only factor associated with tumor recurrence and OS.WHO grade III meningioma is rare, and difficult to manage with a high rate of recurrence and poor OS. Extent of resection is an independent prognostic factor related to tumor recurrence and OS. We could not confirm the usefulness of Ki-67. We suggest that more aggressive treatment, such as safety maximizing cytoreduction by surgery, would improve treatment outcomes.

Subtentorial Meningioma Misdiagnosed as Cerebral Hemorrhage in Postmortem Computed Tomography Imaging: A Case Report

This report presents a case of a 52-year-old man who had a traffic accident and died later. External examination could not determine the cause of death. Approximately 3 weeks later, an autopsy was performed. Postmortem computed tomography was performed before the autopsy. Postmortem imaging was interpreted to show hemorrhage beneath the tentorium, and the C5 to C6 (the fifth and sixth cervical vertebra) disc space was widened. During the autopsy, a cervical spinal cord injury was confirmed. However, a meningioma was found under the tentorium instead of a hemorrhage. There are a number of reasons that include postmortem changes that affected the virtopsy diagnosis, which still needs development.

Adjuvant radiotherapy for atypical meningiomas

OBJECTIVE

The aim of this paper was to evaluate outcomes in patients with atypical meningiomas (AMs) treated with surgery alone compared with surgery and radiotherapy at initial diagnosis, or at the time of first recurrence.

METHODS

Patients with pathologically confirmed AMs treated at the University of Utah from 1991 to 2014 were retrospectively reviewed. Local control (LC), overall survival (OS), Karnofsky Performance Status (KPS), and toxicity were assessed. Outcomes for patients receiving adjuvant radiotherapy were compared with those for patients treated with surgery alone. Kaplan-Meier and the log-rank test for significance were used for LC and OS analyses.

RESULTS

Fifty-nine patients with 63 tumors were reviewed. Fifty-two patients were alive at the time of analysis with a median follow-up of 42 months. LC for all tumors was 57% with a median time to local failure (TTLF) of 48 months. The median TTLF following surgery and radiotherapy was 180 months, compared with 46 months following surgery alone (p = 0.02). Excluding Simpson Grade IV (subtotal) resections, there remained an LC benefit with the addition of radiotherapy for Simpson Grade I, II, and III resected tumors (median TTLF 180 months after surgery and radiotherapy compared with 46 months with surgery alone [p = 0.002]). Patients treated at first recurrence following any initial therapy (either surgery alone or surgery and adjuvant radiotherapy) had a median TTLF of 26 months compared with 48 months for tumors treated at first diagnosis (p = 0.007). There were 2 Grade 3 toxicities and 1 Grade 4 toxicity associated with radiotherapy.

CONCLUSIONS

Adjuvant radiotherapy improves LC for AMs. The addition of adjuvant radiotherapy following even a Simpson Grade I, II, or III resection was found to confer an LC benefit. Recurrent disease is difficult to control, underscoring the importance of aggressive initial treatment.

A giant hyperostotic parasagittal meningioma in a child with neurofibromatosis type II (a case report and literature review)

Large parasagittal meningiomas, in particular hyperostotic ones, in children are rare and problematic in the differential diagnosis. The literature reports only single clinical cases related to this issue; opinions about the indications, surgical treatment options, and prognosis are contradictory. This paper presents a clinical case of a hyperostotic parasagittal meningioma with intra-extracranial growth in a 10-year-old boy with neurofibromatosis type II significantly worsening the prognosis. We discuss the epidemiological and clinical features of childhood meningiomas and issues of their diagnosis, treatment, and prognosis.

Recurrent Atypical Meningiomas: Combining Surgery and Radiosurgery in One Effective Multimodal Treatment

OBJECTIVE

Owing to their rarity and proteiform pathologic features, the clinical behavior of atypical meningiomas is not yet well characterized. Though the extent of resection is believed to be a key determinant of prognosis, limited data exist regarding optimal management of patients with recurrent disease.

METHODS

In this 20-year retrospective case series, we reviewed the medical records of 46 patients with recurrent atypical meningiomas (185 lesions, 89 of which were local, 78 marginal, and 18 distant recurrences); treatment was radiosurgery (n = 60), surgery (n = 56), or both (n = 8). The median follow-up period was 53 months. Outcome measures were length of overall survival and disease-free intervals and prognostic factors for survival.

RESULTS

Overall, the median progression-free survival was 26 months at the first recurrence and 100 months thereafter (the sum of the later intervals). Multivariate analysis showed that no treatment-related factors influenced prognosis, whereas recurrence at the skull base was a significant tumor-related factor limiting further treatment. Irrespective of treatment type, the recurrence-free interval was increasingly shorter during the clinical course, with a higher occurrence of marginal and distant lesions migrating to the midline and to the skull base. In sporadic cases, disease-free intervals were longer after wide craniotomy, tumor and dural resection with tumor-free margin.

CONCLUSIONS

The disease-free interval was substantially similar after surgery and radiosurgery for treating recurrent disease in patients with atypical meningiomas. Surgery is the mainstay for prolonging survival, while radiosurgery can be an adjuvant strategy to gain time for clinical observation and planning aggressive surgical treatment.