Meningioma recurrence: The efficacy and cost-effectiveness of current screening

Conditional Recurrence-Free Survival After Surgical Resection of Meningioma

BACKGROUND

Recurrence after meningioma resection warrants serial surveillance imaging, but little evidence guides the optimal time interval between imaging studies/surveillance duration.

OBJECTIVE

To describe recurrence-free survival (RFS) after meningioma resection, conditioned to short-term RFS.

METHODS

A retrospective cohort study for adults presenting for meningioma resection from 2000 to 2018 was conducted. The primary outcome was postoperative follow-up RFS. Conditional RFS Kaplan-Meier analysis was performed at 1, 2, 3, 5, and 10 years, conditioned to 6-month and 12-month RFS. RFS probabilities conditioned to 6-month RFS were estimated in subgroups, stratified by World Health Organization grade, extent of resection, and need for postoperative radiation.

RESULTS

In total, 723 patients were included. Median age at surgery was 57.4 years (IQR = 47.2-67.2). Median follow-up was 23.5 months (IQR = 12.3-47.8). Recurrence was observed in 90 patients (12%), with median time to recurrence of 14.4 months (IQR = 10.3-37.1). Conditioned to 6-month postoperative RFS, patients had 90.3% probability of remaining recurrence-free at 2 years and 69.4% at 10 years. Subgroup analysis conditioned to 6-month RFS demonstrated grade 1 meningiomas undergoing gross total resection (GTR) had 96.0% probability of RFS at 1 year and 82.8% at 5 years, whereas those undergoing non-GTR had 94.5% and 79.9% probability, respectively. RFS probability was 78.8% at 5 years for non-grade 1 meningiomas undergoing GTR, compared with 69.7% for non-grade 1 meningiomas undergoing non-GTR. Patients with non-grade 1 meningiomas undergoing upfront radiation had a 1-year RFS of 90.1% and 5-year RFS of 51.7%.

CONCLUSION

Recurrence risk after meningioma resection after an initial recurrence-free period is reported, with high-risk subgroups identified. These results can inform objective shared decision-making for optimal follow-up.

Case Report: Recurrent meningioma with multiple metastases

Post-surgery recurrence of meningiomas with multiple extracranial metastases is rare. Currently, information on extracranial metastases is limited, and no clear predictors and standardized treatment protocols can be applied clinically. Herein, we report a case of meningioma that recurred after two surgeries and had multiple distant metastases. Computed tomography revealed multiple enlarged lymph nodes in the para-aortic arch, left lower lung region, retroperitoneum, and abdominopelvic region, as well as soft tissue mass-like lesions under the liver capsule in the right lobe of the liver. Magnetic resonance imaging showed space-occupying lesions under the cranial plate of the left parietal lobe. Tissue biopsy confirmed the diagnosis of recurrent meningioma with extracranial metastases. Immune checkpoint inhibitors and anti-angiogenic drugs were administered. After two treatment cycles, the patient's clinical symptoms were significantly relieved, and the imaging assessment confirmed a stable disease. Although it did not meet our expectations, this combination therapy still demonstrated a possible benefit in improving meningioma patients' survival and quality of life. In this report, along with the case, we also review the relevant literature on the subject and discuss the associated risk factors and treatment options.

Cost-Effectiveness Analysis of 68Ga-DOTATATE PET/MRI in Radiotherapy Planning in Patients with Intermediate-Risk Meningioma

BACKGROUND AND PURPOSE

While contrast-enhanced MR imaging is the criterion standard in meningioma diagnosis and treatment response assessment, gallium 68Ga-DOTATATE PET/MR imaging has increasingly demonstrated utility in meningioma diagnosis and management. Integrating 68Ga-DOTATATE PET/MR imaging in postsurgical radiation planning reduces the planning target volume and organ-at-risk dose. However, 68Ga-DOTATATE PET/MR imaging is not widely implemented in clinical practice due to higher perceived costs. Our study analyzes the cost-effectiveness of 68Ga-DOTATATE PET/MR imaging for postresection radiation therapy planning in patients with intermediate-risk meningioma.

MATERIALS AND METHODS

We developed a decision-analytical model based on both recommended guidelines on meningioma management and our institutional experience. Markov models were implemented to estimate quality-adjusted life-years (QALY). Cost-effectiveness analyses with willingness-to-pay thresholds of $50,000/QALY and $100,000/QALY were performed from a societal perspective. Sensitivity analyses were conducted to validate the results. Model input values were based on published literature.

RESULTS

The cost-effectiveness results demonstrated that 68Ga-DOTATATE PET/MR imaging yields higher QALY (5.47 versus 5.05) at a higher cost ($404,260 versus $395,535) compared with MR imaging alone. The incremental cost-effectiveness ratio analysis determined that 68Ga-DOTATATE PET/MR imaging is cost-effective at a willingness to pay of $50,000/QALY and $100,000/QALY. Furthermore, sensitivity analyses showed that 68Ga-DOTATATE PET/MR imaging is cost-effective at $50,000/QALY ($100,000/QALY) for specificity and sensitivity values above 76% (58%) and 53% (44%), respectively.

CONCLUSIONS

68Ga-DOTATATE PET/MR imaging as an adjunct imaging technique is cost-effective in postoperative treatment planning in patients with meningiomas. Most important, the model results show that the sensitivity and specificity cost-effective thresholds of 68Ga-DOTATATE PET/MR imaging could be attained in clinical practice.

Short-term postoperative surveillance imaging may be unnecessary in elderly patients with resected WHO Grade I meningiomas

The optimal timing and frequency of postoperative imaging surveillance after a meningioma resection are not well-established. The low recurrence rates and slow growth of World Health Organization (WHO) Grade I meningiomas in particular have raised doubts about the utility of postoperative imaging surveillance. We sought to analyze the cost and utility of asymptomatic surveillance imaging in elderly patients after the resection of a WHO Grade I meningioma. We conducted a retrospective cohort study on 45 patients who had a primary WHO Grade I meningioma resected at our institution between 2001-2013 at or above the age of 60 with a minimum of 2 years of follow-up. All postoperative clinic notes were reviewed alongside imaging results to verify that patients were asymptomatic during the surveillance period. MRI and CT scan costs (all $USD) were estimated at $599.61 and $334.31 respectively based on the Centers for Medicare and Medicaid national averages. During an average follow-up period of 4.5 years, the average number of total imaging studies performed per asymptomatic patient was 3.58 with an average total cost of $2086.30 per patient. Forty-two (93%) patients had no new abnormal findings on any of their imaging. Three (7%) patients demonstrated either a new meningioma or progressive growth of the postoperative residual tumor on imaging. No asymptomatic patient underwent a reoperation. Our data suggest that elderly patients with resected WHO Grade I meningiomas are at low risk for recurrence and may not need asymptomatic surveillance imaging for the first several postoperative years.