Paediatric intracranial meningiomas

Proton therapy: A therapeutic opportunity for aggressive pediatric meningioma

Meningiomas are an extremely rare histology among pediatric brain tumors, and there is a shortage of literature on their management. Proton therapy is currently used safely and effectively for many types of both pediatric and adult cancer, and its main advantage is the sparing of healthy tissues from radiation, which could translate in the reduction of late side effects. We review the literature on radiotherapy and proton therapy for pediatric meningiomas and report clinical outcomes for two aggressive pediatric meningiomas we treated with protons. Proton therapy might be a safe and effective therapeutic option for this rare subgroup of tumors.

Pediatric meningiomas: a report of 5 cases and review of literature

PURPOSE

The purpose of this paper is to provide novel insight into the rare pediatric meningiomas.

METHODS

We retrospectively analyzed pediatric surgical cases of meningioma during 2002 to 2017 in our institution. The preoperative, intraoperative, and the postoperative status were collected to find any unique features that has not reported in the past.

RESULTS

Nine surgeries out of 5 patients were identified. The mean age was 7 years old (range 1-14 years old). Four patients were females. The mean tumor diameter was 52 mm (range 23-81 mm). The tumor locations were optic nerve sheath, Sylvian fissure, parasagittal, trigone of the lateral ventricle, and cerebellopontine angle. The Sylvian fissure meningioma without dural attachment (MWODA) was found in a 15-month-old female. A relapsed parasagittal meningioma showed regression in histological grade and residual tumor demonstrated spontaneous regression. In the initial surgeries, Simpson grade 1 resection was achieved in 2 cases. The pathological diagnoses were 1 meningothelial, 1 metaplastic, 2 atypical, and 1 clear cell meningiomas. The mean postoperative follow-up period was 71 months. Three patients experienced recurrence of the tumor. At the latest follow-up, all patients were free of radiological tumor recurrence or regrowth with a mean follow-up of 4 years (range 1-6.9 years). All patients were in the modified Rankin scale of 0-1.

CONCLUSIONS

MWODA is not considered to be rare in pediatric meningioma and should be included in the differential diagnosis. We presented a histologically regressed relapsed meningioma, which spontaneously regressed after subtotal resection. In the case of recurrent meningioma, surgical resection and adjuvant radiation therapy could be effective for long-term control of the tumor.

Intracerebral cystic rhabdoid papillary meningioma in an 11-year-old patient

INTRODUCTION

Rhabdoid papillary meningioma is a rare meningioma variant categorized as WHO grade III. We report an 11-year-old girl with an intracerebral rhabdoid papillary meningioma.

MATERIALS AND METHODS

An 11-year-old girl presented to our hospital with a short history of severe headache and vomiting. MRI revealed a left frontal intracerebral cystic lesion with rim enhancement. The tumor, including the cyst wall, was totally removed. Since the histological diagnosis was rhabdoid papillary meningioma, she was treated with postoperative radiotherapy. She is currently undergoing routine follow-up without any symptoms of recurrence.

CONCLUSION

We discuss the clinical picture of this patient with reference to the published literature on this uncommon diagnosis.

Morbidity in survivors of child and adolescent meningioma

BACKGROUND

The extent of initial surgical resection has been identified as the strongest prognostic indicator for survival in child and adolescent meningioma. Given the paucity of data concerning long-term outcome, the authors undertook a meta-analysis to analyze morbidity in survivors of this disease.

METHODS

Individual patient data were obtained from 19 case series published over the last 23 years through direct communication with the authors. Ordinal logistic regression models were used to assess the influence of risk factors on morbidity.

RESULTS

Of 261 patients, 48% reported a completely normal life with no morbidity, and 25% had moderate/severe meningioma-associated morbidity at last follow-up. Multivariate analysis identified relapse as the only independent variable associated with an increased risk of morbidity (odds ratio, 4.02; 95% confidence interval, 2.11-7.65; P ≤ .001). Univariate analysis also revealed an increased risk for patients with neurofibromatosis (odds ratio, 1.90; 95% confidence interval, 1.04-3.48; P = .04). Subgroup analysis identified a higher incidence of morbidity among patients who had intracranial tumors with a skull base location compared with a nonskull base location (P ≤ .001). Timing at which morbidity occurred was available for 70 patients, with persistence of preoperative tumor-related symptoms in 67% and as a result of therapy in 20%.

CONCLUSIONS

The majority of survivors of child and adolescent meningioma had no or only mild long-term morbidity, whereas 25% had moderate/severe morbidity, with a significantly increased risk in patients with relapsed disease. In the majority, morbidity occurred as a consequence of the tumor itself, justifying aggressive surgery to achieve gross total resection. However, for patients with neurofibromatosis and skull base meningioma, a more cautious surgical approach should be reserved.

Magnetic resonance imaging features of meningiomas in children and young adults: a retrospective analysis

OBJECTIVES

Meningiomas are rare in children and, unlike in adults, they have male predominance, unusual locations, cystic components and poorer clinical outcomes. The aims of our study were to: a) evaluate the MRI features of pediatric meningiomas; b) correlate ADC values of meningiomas with clinical and histopathological types; and c) correlate peritumoral edema with size and histopathological type of tumor.

PATIENTS AND METHODS

Radiological data from 24 patients (mean age: 14.3 years) with an imaging or histopathological diagnosis of meningioma, and presurgical MRI between 1995 and 2009 from two medical institutions, were reviewed. Meningiomas were clinically classified as spontaneously arising meningiomas (SAM), NF2-associated meningiomas (NF2-M) and radiation-induced meningiomas (RIM) and, histopathologically, according to the WHO classification system. The main MRI signal characteristics and enhancement were evaluated. ADC values were compared with histopathological type and clinical group. Tumor size and peritumoral edema were also assessed.

RESULTS

Thirty-four meningiomas (eight SAM, 13 NF2-M, 13 RIM) in 24 patients (12 male, 12 female) were evaluated. Unusual locations were frequently seen in SAM, including cases of intraventricular and intraparenchymal meningiomas. SAM were also always larger than either RIM or NF2-M. Cystic components were only found in SAM, and were not associated with high-grade tumors (WHO II and III). Mean ADC values were significantly different between SAM and NF2-M, but were not associated with histopathological type. Peritumoral edema correlated with tumor size, but did not differ significantly according to clinical group.

CONCLUSION

Pediatric SAM have unusual locations, larger size and cystic components, and are diagnosed at a younger age than NF2-M and RIM. NF2-M can have unusual locations such as, in particular, the craniocervical junction. Tumor ADC values did not help to predict tumor grade or clinical type. Peritumoral edema correlated with tumor size, but not with clinical group or histopathological grade.

MRI findings of intracranial cystic meningiomas

AIM

To report the magnetic resonance imaging (MRI) features of intracranial cystic meningiomas and compare these features in intra- and peritumoural cyst groups.

MATERIALS AND METHODS

Fourteen cases of peritumoural cystic meningiomas were compared with 18 cases of intratumoural cystic meningiomas. All patients were examined using non-enhanced and contrast-enhanced MRI. Tumour location, tumour size, signal intensity, enhancement characteristics, and cystic changes were assessed. The MRI features were compared between the intra- and peritumoural cyst groups.

RESULTS

Most cystic meningiomas comprised two or more cysts. The solid parts of the tumours showed moderate or marked enhancement after the injection of contrast material. An enhanced cyst wall was found in six out of 14 cases in the peritumoural cyst group, but not in the intratumoural cyst group. Peritumoural cystic meningiomas were predominately located in the cerebral falx, whereas the intratumoural cystic meningiomas were predominantly found in frontal convexity (X(2)=7.434, p=0.024). The cysts were larger in the peritumoural cyst group than in the intratumoural cyst group (t=5.274, p=0.0258). Peritumoural oedema was more commonly found in the intratumoural cyst group (X(2)=6.863, p=0.008). Cystic meningiomas with solid parts located inside the cyst are reported for the first time.

CONCLUSION

Cystic meningiomas, although uncommon, should be differentiated from other cystic intracranial lesions. Peri- and intratumoural cystic meningiomas have distinct MRI features. The present study provides the first report of two lesions with solid parts located inside the cyst, as well as one lesion with a calcified solid nodule and haemorrhage within the cyst.

Cystic meninigioma

To study the clinical characteristics of cystic meningiomas, we analyzed retrospectively 21 patients with cystic meningiomas and reviewed the literature with regard to clinical presentation, imaging features, preoperative diagnosis, surgical findings, and histopathological results. The cysts were classified into intratumoral and peritumoral cysts based on their relationship to the tumor, and also according to the classification method described by Nauta. For the 21 patients in our group, there were seven peritumoral cysts and 14 intratumoral cysts. Various pathophysiological mechanisms contribute to the formation of cystic meningiomas. The diagnosis of cystic meningiomas based on CT scan can be problematic, and differentiation from glioma or metastasis may be difficult. MRI scans show low signal intensity areas within the mass on T1-weighted images and high signal intensity areas on T2-weighted images, and the solid parts of tumors are contrast-enhanced after gadolinium administration. MRI with gadolinium enhancement dramatically increases the diagnostic accuracy for cystic meningiomas and provides critical information for their surgical care. Total surgical resection of cystic meningioma is ideal, but special attention should be paid to the cyst walls.

Intracranial meningiomas in children: report of 27 new cases and critical analysis of 440 cases reported in the literature

We accumulated 440 cases of intracranial meningiomas in patients under 16 years of age, and another 27 personal. This review confirms the existence of specific clinical features of spontaneous and radiation-induced meningioma in children. In addition, we discuss various points that suggest a more aggressive behavior of meningiomas in children than in adults. (J Child Neurol 2006;21:31-36).

[Supratentorial meningiomas. Diagnosis, surgical results and complications]

Meningiomas are benign tumors arisising from arachnoid cells and represent the commonest asymptomatic intracranial tumors. We analysed 69 supratentorial meningiomas managed by the Neurosurgical Tumor Group of the Clinics Hospital of Medicine School of São Paulo University (September 1995 to September 1997). Age, sex, edema degree, tumor site, surgical complications and mortality were studied. Edema degree was defined by radiological methods (CT and MRI). Forty-seven patients were women and average age was 58 years. Type II of edema degree was predominant (38.7%). Twenty-nine patients had parasagital meningiomas and 40 presented convexity tumors. Simpson I resection was obtained in 48 procedures, II in 18 and III in two surgical removals. Nine cases complicated (transitory deficits, 6; permanent deficit, 1; and infection, 2). Death occurred in two patients. Morbity and mortality had relation with age, falx tumors and attempt of radical surgical removal. Edema degree did not modify mortality and morbidity rates.

Paediatric meningeal tumours

We review our experience of meningeal tumours in patients under 16 years who were treated between 1957 and 1993. These were 16 with meningiomas (median age 12 years) and 5 with poorly differentiated malignant meningeal tumours (median age 3 years). The incidence of meningeal tumours in this period was 1.62% of all CNS tumours. There were 19 supratentorial tumours (5 intraventricular), 1 tentorial and 1 cervical. Surgical excision was complete in 12 patients and incomplete in 6; in 2 patients a biopsy only was undertaken. The remaining patient had radiological diagnosis only. All 5 patients in the group with malignant poorly differentiated tumours died (median survival 5 months), confirming the aggressive nature of these lesions. Of the 16 patients with meningiomas, 4 died during followup but 11 of the 12 meningioma patients remaining alive had complete resections. There is a strong tendency for paediatric meningeal tumours to have a supratentorial origin and intraventricular location. The female preponderance found in adults is not evident in children. Incomplete surgical excision or focal neurological deficit at presentation was associated with poor outcome.

Cystic meningiomas

BACKGROUND

Meningiomas are generally solid tumors and are easily diagnosed by CT scans and MRI scans. Rarely are these tumors associated with cysts that can cause a confusion in the pre- and intraoperative diagnosis. Cysts associated with meningiomas may be intratumoral or peritumoral.

METHODS

The authors conducted a retrospective study of the seventeen meningiomas, out of a total number of 232, which were associated with cysts. The cysts were classified based on their relationship to the tumor. The patients' sex, age group, location of the tumor, and pathological type of tumor were also analyzed.

RESULTS

The 17 cases of cystic meningioma formed 7.3% of the meningiomas seen between 1984 and 1993. Eleven of these were intratumoral and 6 peritumoral. One case had both intra- and peritumoral cysts. The tumors were found mostly in the fourth and fifth decades of life. Histologically, all the peritumoral cysts except one were associated with meningotheliomatous meningiomas. Tumors with peritumoral cysts were more common in males. Intratumoral cysts, more common in females, were angioblastic or meningotheliomatous on histopathology. Only one case was an anaplastic meningioma.

CONCLUSION

Cysts associated with meningiomas, although uncommon, are certainly not rare. The peritumoral and the intratumoral cysts form distinct subtypes needing separate consideration. Cystic meningiomas are only rarely malignant.

Pediatric cystic meningioma: report of three cases

Three cases of pediatric cystic meningioma are reported. In a review of the literature the authors stress the importance and difficulty of accurate preoperative diagnosis. Cystic meningioma in pediatric patients differs from that in adults in the following respects: higher incidence, predilection for males, shorter clinical history, less specific neuroradiological diagnosis, frequent absence of a dural attachment, prevalence of Nauta type II cystic meningioma, and high incidence of the fibroblastic histotype.

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.

A third ventricular meningioma in a child

A case is presented of a 10-year-old boy with von Recklinghausen's syndrome and multiple meningiomas, one of which was in the third ventricle. The investigation and management of the case is discussed.